Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | SP017123 | PA |
Y | 363LG0600X | Nurse Practitioner - Gerontology | SP017123 | PA |
NPI | 1073050928 |
---|---|
Provider Name | Sophea Bachalis |
First Address | Philadelphia, PA 19104-5127 |
Second Address | Philadelphia, PA 19104-5127 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2017 |
Last Update Date | 13/02/2020 |