MEDICARE: TYREESAH LASHAE WILKERSON-COBB

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	335E00000X	Prosthetic/Orthotic Supplier	807950	PA

General Provider Information

NPI Number	:	1750098760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYREESAH LASHAE WILKERSON-COBB

Provider Business Mailing Address
First Line	:	5613 MASTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-3833
Country	:	US
Telephone Number	:	215-820-8073
Fax Number	:

Provider Business Practice Location Address
First Line	:	5613 MASTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19131-3833
Country	:	US
Telephone Number	:	215-820-8073
Fax Number	:

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

Provider Enumeration Date	:	10/31/2022
Last Update Date	:	10/31/2022

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