Healthcare Provider Details

I. General information

NPI: 1710972336
Provider Name (Legal Business Name): LOREN MASON COBB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3013 S 363RD ST
FEDERAL WAY WA
98003-7249
US

IV. Provider business mailing address

3013 S 363RD ST
FEDERAL WAY WA
98003-7249
US

V. Phone/Fax

Practice location:
  • Phone: 509-991-8589
  • Fax: 253-835-5761
Mailing address:
  • Phone: 509-991-8589
  • Fax: 253-835-5761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number30047
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: