Provider Demographics
NPI:1104906676
Name:GROTTANO, SOFIYA (PA)
Entity type:Individual
Prefix:
First Name:SOFIYA
Middle Name:
Last Name:GROTTANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3511 WEIDNER AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-3535
Mailing Address - Country:US
Mailing Address - Phone:718-904-2767
Mailing Address - Fax:718-904-2799
Practice Address - Street 1:MMC - DEPT. OF OBGYN
Practice Address - Street 2:1825 EASTCHESTER ROAD
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461
Practice Address - Country:US
Practice Address - Phone:718-904-2767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008232363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant