Provider Demographics
NPI:1194781922
Name:SOKOLOV, STACY (CRNA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SOKOLOV
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 N. 15TH ST MS 310
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102
Mailing Address - Country:US
Mailing Address - Phone:215-762-4312
Mailing Address - Fax:215-762-8656
Practice Address - Street 1:245 N. 15TH ST MS 310
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102
Practice Address - Country:US
Practice Address - Phone:215-762-4312
Practice Address - Fax:215-762-8656
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN323167367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA44794Medicare ID - Type Unspecified
PAS70882Medicare UPIN