Basic Information
| Provider Information | |||||||||
| NPI: | 1497386130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSON | ||||||||
| FirstName: | ALEXANDRIA | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| OtherLastName: | SORENSON | ||||||||
| OtherFirstName: | ALEX | ||||||||
| OtherMiddleName: | CHRISTINE | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 920 BOB GLEN CIR | ||||||||
| Address2: | |||||||||
| City: | CENTERTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727194010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172680572 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1704 W INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727562492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794396906 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2020 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.