Provider Demographics
NPI:1639642077
Name:FERNANDES, SOPHIA (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:FERNANDES
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 1:100 WASON AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1179
Mailing Address - Country:US
Mailing Address - Phone:413-386-9040
Mailing Address - Fax:
Practice Address - Street 1:100 WASON AVE STE 100
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1179
Practice Address - Country:US
Practice Address - Phone:413-732-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA6870363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical