MEDICARE: TINA COSBY NURSE PRACTITIONER

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	207QA0505X	Adult Medicine Physician	26NJ01219300	NJ
2	207QA0505X	Adult Medicine Physician	SP024153	PA
3	363LP2300X	Primary Care Nurse Practitioner	SP024153	PA

General Provider Information

NPI Number	:	1831845866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA COSBY NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	1108 ANGORA DR
Second Line	:
City	:	YEADON
State	:	PA
Zip	:	19050-3402
Country	:	US
Telephone Number	:	610-529-7210
Fax Number	:

Provider Business Practice Location Address
First Line	:	602 E BALTIMORE PIKE
Second Line	:
City	:	MEDIA
State	:	PA
Zip	:	19063-1735
Country	:	US
Telephone Number	:	484-444-2834
Fax Number	:	484-444-2592

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

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	04/19/2022

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