Basic Information
| Provider Information | |||||||||
| NPI: | 1174167100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | SOPHIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7469 W RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BROCKPORT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144209429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853313143 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1555 LONG POND RD | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2019 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1159188 | NY | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | PA01390 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.