Provider Demographics
NPI:1710150578
Name:VALDIVIEZO, SONIA (PA)
Entity Type:Individual
Prefix:MRS
First Name:SONIA
Middle Name:
Last Name:VALDIVIEZO
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 1:339 HICKS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5509
Mailing Address - Country:US
Mailing Address - Phone:718-780-1388
Mailing Address - Fax:718-780-1409
Practice Address - Street 1:339 HICKS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5509
Practice Address - Country:US
Practice Address - Phone:718-780-1388
Practice Address - Fax:718-780-1409
Is Sole Proprietor?:No
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005539363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical