Provider Demographics
NPI:1831527373
Name:SHALOMOV, SOFIA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SOFIA
Middle Name:
Last Name:SHALOMOV
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SOFIA
Other - Middle Name:
Other - Last Name:KANDOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2550 N THUNDERBIRD CIR STE 303
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1219
Mailing Address - Country:US
Mailing Address - Phone:623-872-2226
Mailing Address - Fax:
Practice Address - Street 1:9494 W NORTHERN AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85305-1118
Practice Address - Country:US
Practice Address - Phone:623-872-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-18
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant