Provider Demographics
NPI:1578736799
Name:KOBA, TIMOTHY (ATC,CSCS,LMT,CMT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KOBA
Suffix:
Gender:M
Credentials:ATC,CSCS,LMT,CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 MECKLENBURG RD
Mailing Address - Street 2:APT 1
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-9378
Mailing Address - Country:US
Mailing Address - Phone:607-252-3500
Mailing Address - Fax:
Practice Address - Street 1:310 TAUGHANNOCK BVLD
Practice Address - Street 2:SUITE 5A
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-252-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019227225700000X
NY001623-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist