Provider Demographics
NPI:1871912105
Name:SHADDY, SOPHIA (MD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:SHADDY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12209 SE 270TH PL
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-8960
Mailing Address - Country:US
Mailing Address - Phone:419-290-0249
Mailing Address - Fax:
Practice Address - Street 1:12501 E MARGINAL WAY S STE 200
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-5163
Practice Address - Country:US
Practice Address - Phone:206-576-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA60958740207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program