Provider Demographics
NPI:1811392103
Name:PUREVSANGA, ODONTUYA (NP-C)
Entity Type:Individual
Prefix:
First Name:ODONTUYA
Middle Name:
Last Name:PUREVSANGA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 N TAYLOR ST APT 408
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-4774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 PIDGEON HILL DRIVE, SUITE 400
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-6129
Practice Address - Country:US
Practice Address - Phone:703-430-7090
Practice Address - Fax:703-444-9878
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500384NP-PP363LA2200X
MI4704288222363LA2200X
VA0024175395363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1811392103Medicaid