Healthcare Provider Details

I. General information

NPI: 1700156064
Provider Name (Legal Business Name): WILLIAM SOREN MORTENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6630 S MCCARRAN BLVD STE A9
RENO NV
89509-6136
US

IV. Provider business mailing address

6630 S MCCARRAN BLVD STE A9
RENO NV
89509-6136
US

V. Phone/Fax

Practice location:
  • Phone: 775-829-1212
  • Fax: 775-829-1179
Mailing address:
  • Phone: 775-829-1212
  • Fax: 775-829-1179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA123991
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number15717
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: