Provider Demographics
NPI:1114253739
Name:SOPER, THAO PHUNG (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:THAO
Middle Name:PHUNG
Last Name:SOPER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 FRANKLIN SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-3901
Mailing Address - Country:US
Mailing Address - Phone:443-777-7046
Mailing Address - Fax:443-777-7587
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:443-777-7046
Practice Address - Fax:443-777-7587
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054159363A00000X
MDC0004123363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant