Healthcare Provider Details

I. General information

NPI: 1447452826
Provider Name (Legal Business Name): JENNIFER NICOLE SOPKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date: 10/19/2017
Reactivation Date: 11/06/2017

III. Provider practice location address

825 NW HIGHWAY 101 STE A
LINCOLN CITY OR
97367-3241
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-996-7480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055.0031594
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number021537
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2342
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA218759
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: