Healthcare Provider Details

I. General information

NPI: 1720648157
Provider Name (Legal Business Name): NATHAN ANDREW COBB DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 10/25/2024
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 HIGHLANDS PLAZA DR E STE 220
SAINT LOUIS MO
63110-1351
US

IV. Provider business mailing address

1110 HIGHLANDS PLAZA DR E STE 220
SAINT LOUIS MO
63110-1351
US

V. Phone/Fax

Practice location:
  • Phone: 314-273-0195
  • Fax:
Mailing address:
  • Phone: 314-273-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101026044
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2022020790
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5151013682
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: