Provider Demographics
NPI:1386093102
Name:KOBORDO, KRYSTAL (PTA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:KOBORDO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 ARAPAHOE AVE UNIT 317
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-3303
Mailing Address - Country:US
Mailing Address - Phone:484-375-5789
Mailing Address - Fax:
Practice Address - Street 1:1667 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-1614
Practice Address - Country:US
Practice Address - Phone:303-399-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0013781225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant