Healthcare Provider Details

I. General information

NPI: 1366282220
Provider Name (Legal Business Name): GERARD KOBEANE PAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E PARKWAY S
MEMPHIS TN
38104-5519
US

IV. Provider business mailing address

650 E PARKWAY S
MEMPHIS TN
38104-5519
US

V. Phone/Fax

Practice location:
  • Phone: 901-321-3388
  • Fax:
Mailing address:
  • Phone: 901-321-3388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: