Basic Information
| Provider Information | |||||||||
| NPI: | 1760430078 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSON-LAVALLEY | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAVALLEY | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772700 | ||||||||
| FaxNumber: | 6088772726 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CHURCH ST | ||||||||
| Address2: | DEAN MEDICAL CENTER | ||||||||
| City: | STOUGHTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535891801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088772700 | ||||||||
| FaxNumber: | 6088772726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 09/29/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 381-023 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 381-023 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 42909700 | 05 | WI | MEDICAID | 3990 | 01 | WI | DEAN HEALTH INSURANCE | OTHER |