Provider Demographics
NPI:1659702686
Name:SOFFERMAN, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SOFFERMAN
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 1:1129 NORTHERN BLVD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3045
Mailing Address - Country:US
Mailing Address - Phone:516-627-2121
Mailing Address - Fax:516-627-4922
Practice Address - Street 1:1129 NORTHERN BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3045
Practice Address - Country:US
Practice Address - Phone:516-627-2121
Practice Address - Fax:516-627-4922
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017229363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical