Provider Demographics
NPI:1679971378
Name:LYNCH, SOPHIA YVETTE (PA)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:YVETTE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:YVETTE
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4724 N DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2339
Mailing Address - Country:US
Mailing Address - Phone:850-696-4000
Mailing Address - Fax:
Practice Address - Street 1:1921 E NINE MILE RD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514
Practice Address - Country:US
Practice Address - Phone:850-696-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0PJ3OtherBCBSFL
FL013963200Medicaid
FLY0PJ3OtherBCBSFL