Provider Demographics
NPI:1174944771
Name:KOBUK, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KOBUK
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 1:94 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:AK
Mailing Address - Zip Code:99659
Mailing Address - Country:US
Mailing Address - Phone:907-923-3311
Mailing Address - Fax:907-923-2287
Practice Address - Street 1:94 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SAINT MICHAEL
Practice Address - State:AK
Practice Address - Zip Code:99659
Practice Address - Country:US
Practice Address - Phone:907-923-3311
Practice Address - Fax:907-923-2287
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK12-1218-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK12-1218-IIIOtherCHA III