Healthcare Provider Details

I. General information

NPI: 1336050459
Provider Name (Legal Business Name): SOPHIA SEERANOUSH ANTEBIAN ATS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 HASTINGS ROAD
STATE COLLEGE PA
16802
US

IV. Provider business mailing address

15990 EMILY CORLETT
MARSHALL MI
49068-8311
US

V. Phone/Fax

Practice location:
  • Phone: 949-910-5509
  • Fax:
Mailing address:
  • Phone: 949-910-5509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: