Healthcare Provider Details

I. General information

NPI: 1053339663
Provider Name (Legal Business Name): JOSEPH STANLEY SOPARAS PA-C/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEDOM WAY # 291
AUGUSTA GA
30904-6258
US

IV. Provider business mailing address

1 FREEDOM WAY # 291
AUGUSTA GA
30904-6258
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-481-6703
Mailing address:
  • Phone: 706-733-0188
  • Fax: 706-481-6703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001714
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: