Provider Demographics
NPI:1942080270
Name:SMITH, SOPHIE MAE
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:MAE
Last Name:SMITH
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 1:1441 AZUAR DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1017
Mailing Address - Country:US
Mailing Address - Phone:858-395-8393
Mailing Address - Fax:
Practice Address - Street 1:1310 CLUB DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94592-1187
Practice Address - Country:US
Practice Address - Phone:707-638-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant