Provider Demographics
NPI:1902877087
Name:RODRIGUEZ-SOUTHWORTH, SYLVIA (PA)
Entity Type:Individual
Prefix:
First Name:SYLVIA
Middle Name:
Last Name:RODRIGUEZ-SOUTHWORTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SYLVIA
Other - Middle Name:
Other - Last Name:SOUTHWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 BEACON HILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-6178
Practice Address - Country:US
Practice Address - Phone:606-780-0444
Practice Address - Fax:606-784-2344
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA123363A00000X
KYPA-123363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPA123OtherKY STATE LICENSE
KYPA123OtherKY STATE LICENSE