Provider Demographics
NPI:1538059571
Name:COBB, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:COBB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 WOODSOME RD
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3318
Mailing Address - Country:US
Mailing Address - Phone:631-495-0085
Mailing Address - Fax:
Practice Address - Street 1:1745 UNION BLVD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7952
Practice Address - Country:US
Practice Address - Phone:631-323-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312351363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health