Provider Demographics
NPI:1700225844
Name:SORONGON, IDA PRAILE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:PRAILE
Last Name:SORONGON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8936 SPANISH RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-1354
Mailing Address - Country:US
Mailing Address - Phone:702-998-2816
Mailing Address - Fax:702-998-2991
Practice Address - Street 1:3343 S EASTERM AVENUE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169
Practice Address - Country:US
Practice Address - Phone:702-731-0909
Practice Address - Fax:702-731-1020
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVAPN001519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1700225844Medicaid