Provider Demographics
NPI:1578198115
Name:EMBORGO, TRISHA SOFIA GALICIA
Entity Type:Individual
Prefix:
First Name:TRISHA SOFIA
Middle Name:GALICIA
Last Name:EMBORGO
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 1:190 BEACH 69TH ST APT 2A
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1369
Mailing Address - Country:US
Mailing Address - Phone:936-553-2532
Mailing Address - Fax:
Practice Address - Street 1:1858 W GRANDVIEW BLVD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-1025
Practice Address - Country:US
Practice Address - Phone:936-553-2532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-04
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program