Provider Demographics
NPI:1962153452
Name:LIU, SOUDARATH (APRN)
Entity type:Individual
Prefix:
First Name:SOUDARATH
Middle Name:
Last Name:LIU
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 1:5418 S FIREPLACE DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4601
Mailing Address - Country:US
Mailing Address - Phone:479-685-2237
Mailing Address - Fax:
Practice Address - Street 1:1401 N WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4676
Practice Address - Country:US
Practice Address - Phone:479-319-5355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-16
Last Update Date:2022-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR217965363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care