Provider Demographics
NPI:1073034872
Name:LIDDELL, SORIYA (AGACNP)
Entity Type:Individual
Prefix:
First Name:SORIYA
Middle Name:
Last Name:LIDDELL
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6017 E CAMINO MANZANO
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-3216
Mailing Address - Country:US
Mailing Address - Phone:562-761-4218
Mailing Address - Fax:
Practice Address - Street 1:28062 BAXTER RD
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1401
Practice Address - Country:US
Practice Address - Phone:951-290-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006824363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care