Healthcare Provider Details

I. General information

NPI: 1932605862
Provider Name (Legal Business Name): SOPHIA CACCAVALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 03/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ELM ST
GREENSBORO NC
27401-1004
US

IV. Provider business mailing address

PO BOX 10467 1200 NORTH ELM ST
GREENSBORO NC
27404-0467
US

V. Phone/Fax

Practice location:
  • Phone: 336-207-7005
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-07997
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: