Healthcare Provider Details

I. General information

NPI: 1316267222
Provider Name (Legal Business Name): SOPHIA MARIE GOVOROV P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W ALLEGHENY AVENUE UNITE B-5
PHILADELPHIA PA
19133
US

IV. Provider business mailing address

1412 FAIRMOUNT AVE
PHILADELPHIA PA
19130-2908
US

V. Phone/Fax

Practice location:
  • Phone: 215-207-0522
  • Fax: 215-291-2582
Mailing address:
  • Phone: 215-599-4851
  • Fax: 215-232-4093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053247
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: