Healthcare Provider Details

I. General information

NPI: 1003813866
Provider Name (Legal Business Name): MICHAEL JOHN COBB PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

962 WARWICK AVE
WARWICK RI
02888-3650
US

IV. Provider business mailing address

104 CAMERON WAY
REHOBOTH MA
02769-2126
US

V. Phone/Fax

Practice location:
  • Phone: 401-612-7100
  • Fax: 774-565-0469
Mailing address:
  • Phone: 813-326-7937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00255
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00255
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: