Provider Demographics
NPI:1164164497
Name:VASILYEVA, SOFIA NIKOLAYEVNA (PA)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:NIKOLAYEVNA
Last Name:VASILYEVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W. 140TH ST.
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337
Mailing Address - Country:US
Mailing Address - Phone:952-435-0303
Mailing Address - Fax:952-892-5166
Practice Address - Street 1:1000 W. 140TH ST.
Practice Address - Street 2:SUITE #100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337
Practice Address - Country:US
Practice Address - Phone:952-435-0303
Practice Address - Fax:952-892-5166
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14242363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14242OtherMN PA LICENSE