Provider Demographics
NPI:1043712383
Name:SOPKA, GREGORY (PA)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:
Last Name:SOPKA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 WESTERN MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9447
Mailing Address - Country:US
Mailing Address - Phone:810-347-1881
Mailing Address - Fax:
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty