Provider Demographics
NPI:1528434362
Name:FISKE, SOFIA (PA-C)
Entity type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:FISKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 SUTTER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4009
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:1627 I ST NW STE 800
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20006-4088
Practice Address - Country:US
Practice Address - Phone:202-660-0015
Practice Address - Fax:202-660-0025
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031576363AM0700X
MDC0005859363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0005859OtherMD LICENSE NUMBER