Healthcare Provider Details

I. General information

NPI: 1538057153
Provider Name (Legal Business Name): JACK KOBURGER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 DEL PRADO BLVD S
CAPE CORAL FL
33990-2668
US

IV. Provider business mailing address

6796 SMOKERISE DR
MACCLENNY FL
32063-5256
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-3513
  • Fax:
Mailing address:
  • Phone: 904-312-2297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9120347
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: