Healthcare Provider Details

I. General information

NPI: 1760396451
Provider Name (Legal Business Name): HALEY SODERBLOOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL CENTER BLVD DEPT OF OTOLARYNGOLOGY HEAD & NECK SURGERY
WINSTON SALEM NC
27157-1034
US

IV. Provider business mailing address

MEDICAL CENTER BLVD DEPT OF OTOLARYNGOLOGY HEAD & NECK SURGERY
WINSTON SALEM NC
27157-1034
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-4161
  • Fax: 336-716-3857
Mailing address:
  • Phone: 336-716-4161
  • Fax: 336-716-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-17144
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: