Basic Information
| Provider Information | |||||||||
| NPI: | 1073933529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOPCZAK | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SOPCZAK | ||||||||
| OtherFirstName: | ANTHONY | ||||||||
| OtherMiddleName: | PATRICK | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 CAISSON HILL RD | ||||||||
| Address2: | |||||||||
| City: | FORT RILEY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664427037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7852407227 | ||||||||
| FaxNumber: | 7852397364 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 DECATUR PIKE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373032418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237461412 | ||||||||
| FaxNumber: | 4237456413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 3669 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 1117328 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.