Provider Demographics
NPI:1336537547
Name:RO, SOPHIA EUN (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:EUN
Last Name:RO
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 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:3357B CORRIDOR MARKETPLACE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20724-2381
Practice Address - Country:US
Practice Address - Phone:301-497-1820
Practice Address - Fax:301-497-5489
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD517909ZDDBMedicare PIN
MD517591YWV2Medicare PIN
MD517909YVZMedicare PIN