Provider Demographics
NPI:1710920855
Name:SORENSEN, SCOTT H (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:H
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:PA-C
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 746093
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:745 E GUADALUPE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2911
Practice Address - Country:US
Practice Address - Phone:480-618-0123
Practice Address - Fax:520-300-8051
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1274363A00000X, 363AM0700X
AZ9819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470376604-32Medicaid
IAORDERING/REFERRINGMedicaid
NE470376604-32Medicaid