Healthcare Provider Details

I. General information

NPI: 1417437625
Provider Name (Legal Business Name): SOPAGNA BANH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2018
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD STE 5A43
NEWARK DE
19718-2200
US

IV. Provider business mailing address

5601 LOCH RAVEN BLVD
BALTIMORE MD
21239-2950
US

V. Phone/Fax

Practice location:
  • Phone: 302-623-0188
  • Fax: 302-733-5640
Mailing address:
  • Phone: 443-444-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC5-0012496
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006946
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: