=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336268614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NASRIN SOROCK SISK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2007
-----------------------------------------------------
Last Update Date | 08/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 COVE TOWER DR APT 201
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-6087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-644-7551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 VARNUM ST NE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20017-2145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-269-7430
-----------------------------------------------------
Fax | 202-269-7328
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | ME152188
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------