Basic Information
| Provider Information | |||||||||
| NPI: | 1588647374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORRENTINO | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1839 S ALMA SCHOOL RD STE 354 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852103028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4807262287 | ||||||||
| FaxNumber: | 8883169272 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 N CENTRAL AVE STE 120 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022964060 | ||||||||
| FaxNumber: | 6022964146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 7209350001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7045160001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7047150001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7046960001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7629170001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7057360001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332B00000X | 7034950001 | AZ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 363A00000X | 25MP00072600 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3649 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-08611 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.