Provider Demographics
NPI:1265096424
Name:HACKNEY, SOPHIA DELISE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SOPHIA
Middle Name:DELISE
Last Name:HACKNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12112 S 83RD EAST AVE APT 422
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3344
Mailing Address - Country:US
Mailing Address - Phone:405-308-5490
Mailing Address - Fax:
Practice Address - Street 1:8282 S MEMORIAL DR STE 106
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4311
Practice Address - Country:US
Practice Address - Phone:918-579-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3052363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant