Healthcare Provider Details

I. General information

NPI: 1760610497
Provider Name (Legal Business Name): SOFIA R. BULAHAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COPPEROPOLIS FAMILY MEDICAL CLINIC 3505 SPANGLER LANE, SUITE 400
COPPEROPOLIS CA
95228
US

IV. Provider business mailing address

MARK TWAIN MEDICAL CENTER 768 MOUNTAIN RANCH ROAD
SAN ANDREAS CA
95249
US

V. Phone/Fax

Practice location:
  • Phone: 209-785-7000
  • Fax:
Mailing address:
  • Phone: 209-754-3521
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17924-N
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: