Provider Demographics
NPI:1720356363
Name:NYSWYN, SOPHIA (PA)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:NYSWYN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:SOPHIA
Other - Last Name:GLADSTON SOLOMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:520 S EAGLE RD
Practice Address - Street 2:STE 3112
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6351
Practice Address - Country:US
Practice Address - Phone:208-706-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-10
Last Update Date:2011-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant