Provider Demographics
NPI:1356956064
Name:ROA, SORAYA (APRN)
Entity type:Individual
Prefix:
First Name:SORAYA
Middle Name:
Last Name:ROA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4606 FALCON AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-6711
Mailing Address - Country:US
Mailing Address - Phone:407-883-3885
Mailing Address - Fax:
Practice Address - Street 1:14015 EGRET TOWER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6197
Practice Address - Country:US
Practice Address - Phone:407-447-7100
Practice Address - Fax:407-447-6100
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY346903363LF0000X
KY3018633363LF0000X
FL11009033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPW929OtherMEDICARE
FL108820800Medicaid