Basic Information
| Provider Information | |||||||||
| NPI: | 1205153699 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SONNETT | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | ELLIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 N BEAVER ST | ||||||||
| Address2: | |||||||||
| City: | FLAGSTAFF | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860013118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282136235 | ||||||||
| FaxNumber: | 9282136292 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 S WILLARD ST | ||||||||
| Address2: | |||||||||
| City: | COTTONWOOD | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863264126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286396025 | ||||||||
| FaxNumber: | 9286341117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2010 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 4614 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 519850 | 05 | AZ | MEDICAID |