Healthcare Provider Details

I. General information

NPI: 1013114701
Provider Name (Legal Business Name): O'LAF SORENTO MASSENBURG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 12/21/2025
Certification Date: 03/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 NC HIGHWAY 65 SUITE 204
REIDSVILLE NC
27320-8881
US

IV. Provider business mailing address

1021 DARRINGTON DR STE 101
CARY NC
27513-8158
US

V. Phone/Fax

Practice location:
  • Phone: 336-342-8143
  • Fax: 336-342-8356
Mailing address:
  • Phone: 336-286-5505
  • Fax: 336-286-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number101117
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number101117
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: