Provider Demographics
NPI:1972026276
Name:BURGE, SOPHIA WAGNER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SOPHIA
Middle Name:WAGNER
Last Name:BURGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SOPHIA
Other - Middle Name:JANE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1800 15TH ST STE 340
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80631-4562
Mailing Address - Country:US
Mailing Address - Phone:970-810-4593
Mailing Address - Fax:970-810-4591
Practice Address - Street 1:1800 15TH ST STE 340
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-4562
Practice Address - Country:US
Practice Address - Phone:970-810-4593
Practice Address - Fax:970-810-4591
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
COPA.0005117363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical