Healthcare Provider Details

I. General information

NPI: 1023727757
Provider Name (Legal Business Name): BEAU BRADLEY SORENSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4612 PRAIRIE PKWY
CEDAR FALLS IA
50613-7971
US

IV. Provider business mailing address

PO BOX 2758
WATERLOO IA
50704-2758
US

V. Phone/Fax

Practice location:
  • Phone: 319-859-8139
  • Fax:
Mailing address:
  • Phone: 319-235-5390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number118465
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number118465
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: