Provider Demographics
NPI:1508294810
Name:SORAPURU, ANJENETTE MORANDA (NP)
Entity Type:Individual
Prefix:
First Name:ANJENETTE
Middle Name:MORANDA
Last Name:SORAPURU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S ELISEO DR STE 1
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2017
Mailing Address - Country:US
Mailing Address - Phone:415-514-6868
Mailing Address - Fax:
Practice Address - Street 1:1100 S ELISEO DR STE 1
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2017
Practice Address - Country:US
Practice Address - Phone:415-514-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218352363LA2100X
LAAP07266363LA2100X
CA95023811363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508294810Medicaid