Provider Demographics
NPI:1023727757
Name:SORENSON, BEAU BRADLEY (PA)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:BRADLEY
Last Name:SORENSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:
Practice Address - Street 1:4612 PRAIRIE PKWY
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613-7971
Practice Address - Country:US
Practice Address - Phone:319-859-8139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA118465363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical