Healthcare Provider Details

I. General information

NPI: 1063516136
Provider Name (Legal Business Name): JONATHAN L SORENSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GOOD SAMARITAN WAY SUITE 205
MOUNT VERNON IL
62864-2408
US

IV. Provider business mailing address

4227 LINCOLNSHIRE DR
MOUNT VERNON IL
62864-2157
US

V. Phone/Fax

Practice location:
  • Phone: 618-241-1108
  • Fax: 618-241-3805
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209000414
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: