Healthcare Provider Details

I. General information

NPI: 1124302344
Provider Name (Legal Business Name): MATTHEW M SORAK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-1782
  • Fax: 860-545-1784
Mailing address:
  • Phone: 860-545-1782
  • Fax: 860-545-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: