Provider Demographics
NPI:1083943062
Name:STARAYEVA, SOFIA
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:STARAYEVA
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 1:9825 HORACE HARDING EXPY APT 7B
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-4608
Mailing Address - Country:US
Mailing Address - Phone:917-981-1177
Mailing Address - Fax:
Practice Address - Street 1:9825 HORACE HARDING EXPY APT 7B
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-4608
Practice Address - Country:US
Practice Address - Phone:917-981-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY365684091174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYUJ42288AMedicaid