Basic Information
Provider Information
NPI: 1003803263
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KOBERNA
FirstName: PAUL
MiddleName: ANDREW
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2134 SANDY DR STE 16
Address2:  
City: STATE COLLEGE
State: PA
PostalCode: 168032292
CountryCode: US
TelephoneNumber: 8142725805
FaxNumber: 8142720110
Practice Location
Address1: 2134 SANDY DR STE 16
Address2:  
City: STATE COLLEGE
State: PA
PostalCode: 168032292
CountryCode: US
TelephoneNumber: 8142725805
FaxNumber: 8142720110
Other Information
ProviderEnumerationDate: 10/03/2005
LastUpdateDate: 10/31/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XMD062353-LPAY Allopathic & Osteopathic PhysiciansInternal Medicine 
207RC0200XMD062353-LPAN Allopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine

ID Information
IDTypeStateIssuerDescription
5000080501PACAPITAL BC/BSOTHER
2192001PAGEISINGEROTHER
95276101PAHIGHMARK BSOTHER
001645500000305PA MEDICAID
11023765401PARAILROAD MEDICAREOTHER


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