Healthcare Provider Details

I. General information

NPI: 1881264455
Provider Name (Legal Business Name): DEMITTRE ANDRE ANTHONY SORENSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 CONCOURSE PKWY S STE 200
MAITLAND FL
32751-8101
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-4014
  • Fax:
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114808
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: