Provider Demographics
NPI:1821226085
Name:KOBAN, JAMIE L (PNP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:KOBAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 HARLEM RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4031
Mailing Address - Country:US
Mailing Address - Phone:716-893-7337
Mailing Address - Fax:716-893-7699
Practice Address - Street 1:2625 HARLEM RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4031
Practice Address - Country:US
Practice Address - Phone:716-893-7337
Practice Address - Fax:716-893-7699
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382071363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03121359Medicaid