Healthcare Provider Details

I. General information

NPI: 1962736348
Provider Name (Legal Business Name): FAMILY MEDICINE & WEIGHT MANAGEMENT SPECIALTY, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 S AVENUE A
YUMA AZ
85364-8315
US

IV. Provider business mailing address

2189 S. AVENUE A, SUITE A
YUMA AZ
85364-8880
US

V. Phone/Fax

Practice location:
  • Phone: 928-276-4381
  • Fax:
Mailing address:
  • Phone: 928-276-4381
  • Fax: 928-276-9086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4158
License Number StateAZ

VIII. Authorized Official

Name: KIRSTEN A SORENSEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-431-1152