Provider Demographics
NPI:1124014865
Name:COBLE, JAYSON A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAYSON
Middle Name:A
Last Name:COBLE
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 1:205 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-1637
Mailing Address - Country:US
Mailing Address - Phone:217-622-0110
Mailing Address - Fax:217-761-2910
Practice Address - Street 1:1301 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2317
Practice Address - Country:US
Practice Address - Phone:217-789-6030
Practice Address - Fax:217-761-2910
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002176363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08116Medicare UPIN
ILK03987Medicare ID - Type Unspecified