Healthcare Provider Details

I. General information

NPI: 1407896483
Provider Name (Legal Business Name): NATHANIEL COBB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 9TH AVE
TRUTH OR CONSEQUENCES NM
87901-1954
US

IV. Provider business mailing address

PO BOX 2939
CORRALES NM
87048-2939
US

V. Phone/Fax

Practice location:
  • Phone: 505-894-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number85-156
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: