Healthcare Provider Details

I. General information

NPI: 1811721319
Provider Name (Legal Business Name): SOFIYA ALEXIS PRUSS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10012 KENNERLY RD STE 102
SAINT LOUIS MO
63128-2197
US

IV. Provider business mailing address

10012 KENNERLY RD STE 102
SAINT LOUIS MO
63128-2197
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5911
  • Fax: 314-543-5914
Mailing address:
  • Phone: 314-543-5911
  • Fax: 314-543-5914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024040291
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: