Healthcare Provider Details

I. General information

NPI: 1881406619
Provider Name (Legal Business Name): SOPHIA CYNTHIA RILEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 LIBERTY DR
HANOVER MN
55341-1301
US

IV. Provider business mailing address

364 LIBERTY DR
HANOVER MN
55341-1301
US

V. Phone/Fax

Practice location:
  • Phone: 763-258-4916
  • Fax:
Mailing address:
  • Phone: 763-258-4916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: