Healthcare Provider Details

I. General information

NPI: 1295647295
Provider Name (Legal Business Name): SOPHIA MARTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 OVERTON GROVE WAY APT 236
BRANDON FL
33511-2392
US

IV. Provider business mailing address

655 OVERTON GROVE WAY APT 236
BRANDON FL
33511-2392
US

V. Phone/Fax

Practice location:
  • Phone: 812-480-9674
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9122314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: