Basic Information
| Provider Information | |||||||||
| NPI: | 1861943078 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SORELL | ||||||||
| FirstName: | SAMERA | ||||||||
| MiddleName: | AVERILL | ||||||||
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| Credential: | C.N.M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1555 LONG POND RD | ||||||||
| Address2: | OB/GYN DEPARTMENT | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684006 | ||||||||
| FaxNumber: | 5853684009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 LONG POND RD | ||||||||
| Address2: | OB/GYN DEPARTMENT | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146264122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853684006 | ||||||||
| FaxNumber: | 5853684009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2016 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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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 | 367A00000X | 001762 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 04612373 | 05 | NY | MEDICAID |