MEDICARE: TYLER COBB MAT, ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1134962392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER COBB MAT, ATC

Provider Business Mailing Address
First Line	:	1309 S 2ND ST
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2125
Country	:	US
Telephone Number	:	812-568-7965
Fax Number	:

Provider Business Practice Location Address
First Line	:	1309 S 2ND ST
Second Line	:
City	:	BOONVILLE
State	:	IN
Zip	:	47601-2125
Country	:	US
Telephone Number	:	812-568-7965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/10/2026

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