MEDICARE: MEGAN SUSANNE SOFKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	DO2023-0413	NM

General Provider Information

NPI Number	:	1083233357
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MEGAN SUSANNE SOFKA

Provider Business Mailing Address
First Line	:	4421 SUPERSTITION DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-7514
Country	:	US
Telephone Number	:	505-306-7437
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 PRINCETON DR SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-3019
Country	:	US
Telephone Number	:	505-346-7656
Fax Number	:	505-485-0560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	12/13/2023

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