Provider Demographics
NPI:1003813866
Name:COBB, MICHAEL JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:COBB
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CAMERON WAY
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH
Mailing Address - State:MA
Mailing Address - Zip Code:02769-2126
Mailing Address - Country:US
Mailing Address - Phone:813-326-7937
Mailing Address - Fax:
Practice Address - Street 1:962 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3650
Practice Address - Country:US
Practice Address - Phone:401-612-7100
Practice Address - Fax:774-565-0469
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00255363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7008957Medicaid
RI97903073Medicare PIN
RIP21676Medicare UPIN