Healthcare Provider Details

I. General information

NPI: 1942876750
Provider Name (Legal Business Name): SOFIA EDDA CAPUA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 MAIN ST STE 5
SPRINGFIELD MA
01107-1142
US

IV. Provider business mailing address

3455 MAIN ST STE 5
SPRINGFIELD MA
01107-1142
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-9600
  • Fax: 413-732-6534
Mailing address:
  • Phone: 413-733-9600
  • Fax: 413-732-6534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA8127
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: