Provider Demographics
NPI:1841241189
Name:PRAK, SOPHEAVY S (CFNP)
Entity Type:Individual
Prefix:
First Name:SOPHEAVY
Middle Name:S
Last Name:PRAK
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CIELO AZUL
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-9631
Mailing Address - Country:US
Mailing Address - Phone:505-890-6509
Mailing Address - Fax:
Practice Address - Street 1:4808 MCMAHON BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5010
Practice Address - Country:US
Practice Address - Phone:505-272-2900
Practice Address - Fax:505-272-2909
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR37588363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPENDINGMedicaid
NMPENDINGMedicaid
NMP54233Medicare UPIN