Provider Demographics
NPI:1194419663
Name:MARINO, SOPHIA SHEA (PA-C)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:SHEA
Last Name:MARINO
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 1:10 COUNTRY CLUB PL W
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1108 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3022
Practice Address - Country:US
Practice Address - Phone:334-793-8111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
GA12242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical