MEDICARE: ODONTUYA PUREVSANGA NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	201500384NP-PP	OR
2	363LA2200X	Adult Health Nurse Practitioner	4704288222	MI
3	363LA2200X	Adult Health Nurse Practitioner	0024175395	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811392103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ODONTUYA PUREVSANGA NP-C

Provider Business Mailing Address
First Line	:	1050 N TAYLOR ST APT 408
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-4774
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2 PIDGEON HILL DRIVE, SUITE 400
Second Line	:
City	:	STERLING
State	:	VA
Zip	:	20165-6129
Country	:	US
Telephone Number	:	703-430-7090
Fax Number	:	703-444-9878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/29/2014
Last Update Date	:	01/10/2024

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