Basic Information
| Provider Information | |||||||||
| NPI: | 1851870919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SORENSON | ||||||||
| FirstName: | MARY JANE | ||||||||
| MiddleName: | WILD | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1857 N SPRINGER MOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | LAKESIDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859296617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207303074 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859017831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285374375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 08/09/2018 | ||||||||
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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 | 363LF0000X | AP11648 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.