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General NPI Number Information
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NPI Number | 1265096424
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Entity Type | Individual
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Provider Name | SOPHIA DELISE HACKNEY PA-C
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Gender | Female
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Dates
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Enumeration Date | 04/23/2019
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Last Update Date | 06/17/2019
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Provider Practice Location Address
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Address Line | 8282 S MEMORIAL DR STE 106
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City | TULSA
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State | OK
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Zip | 74133-4311
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Country | US
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Telephone | 918-579-4200
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Fax |
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Provider Business Mailing Address
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Address Line | 12112 S 83RD EAST AVE APT 422
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City | BIXBY
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State | OK
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Zip | 74008-3344
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Country | US
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Telephone | 405-308-5490
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 3052
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License Number State | OK
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