MEDICARE: SOFIYA ALEXIS PRUSS PA-C

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	363A00000X	Physician Assistant	2024040291	MO

General Provider Information

NPI Number	:	1811721319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOFIYA ALEXIS PRUSS PA-C

Provider Business Mailing Address
First Line	:	10012 KENNERLY RD STE 102
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2197
Country	:	US
Telephone Number	:	314-543-5911
Fax Number	:	314-543-5914

Provider Business Practice Location Address
First Line	:	10012 KENNERLY RD STE 102
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-2197
Country	:	US
Telephone Number	:	314-543-5911
Fax Number	:	314-543-5914

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

Provider Enumeration Date	:	08/27/2024
Last Update Date	:	06/16/2026

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Directions to “ SOFIYA ALEXIS PRUSS PA-C” Practice Location

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