Provider Demographics
NPI:1124485537
Name:KOBORDO, TIFFANY ANN (ATC, OTC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:KOBORDO
Suffix:
Gender:F
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6042
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CO
Mailing Address - Zip Code:81620-6042
Mailing Address - Country:US
Mailing Address - Phone:610-751-5912
Mailing Address - Fax:
Practice Address - Street 1:181 W MEADOW DR STE 400
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5058
Practice Address - Country:US
Practice Address - Phone:970-476-2451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSA.0002071246ZC0007X
15-1138246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant