Provider Demographics
NPI:1750098760
Name:WILKERSON-COBB, TYREESAH LASHAE
Entity type:Individual
Prefix:
First Name:TYREESAH
Middle Name:LASHAE
Last Name:WILKERSON-COBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5613 MASTER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-3833
Mailing Address - Country:US
Mailing Address - Phone:215-820-8073
Mailing Address - Fax:
Practice Address - Street 1:5613 MASTER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-3833
Practice Address - Country:US
Practice Address - Phone:215-820-8073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA807950335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier