Healthcare Provider Details

I. General information

NPI: 1720335904
Provider Name (Legal Business Name): TERRY DANIEL KOBER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 SULLIVAN ST
RIVERVIEW FL
33578-2140
US

IV. Provider business mailing address

900 S PINE ISLAND RD SUITE 800
PLANTATION FL
33324-3920
US

V. Phone/Fax

Practice location:
  • Phone: 813-689-7571
  • Fax: 813-654-8129
Mailing address:
  • Phone: 813-689-7571
  • Fax: 813-654-8129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1440
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9105264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: