Provider Demographics
NPI:1750760799
Name:CUSTER, SOPHIA (PA)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:MCGUIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:625 S NEW BALLAS RD STE 7020
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8218
Mailing Address - Country:US
Mailing Address - Phone:314-251-6486
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015007863363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant