Provider Demographics
NPI:1558089474
Name:LEX, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:LEX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 S 8TH AVE STOP 8253
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-0002
Mailing Address - Country:US
Mailing Address - Phone:208-282-4726
Mailing Address - Fax:
Practice Address - Street 1:921 S 8TH AVE STOP 8253
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-0002
Practice Address - Country:US
Practice Address - Phone:208-282-4726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14190372-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant