Healthcare Provider Details

I. General information

NPI: 1982384996
Provider Name (Legal Business Name): MAELIN SORENSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 ROUND VALLEY DR
PARK CITY UT
84060-7571
US

IV. Provider business mailing address

195 S 80 E
MIDWAY UT
84049-6618
US

V. Phone/Fax

Practice location:
  • Phone: 435-333-1850
  • Fax:
Mailing address:
  • Phone: 435-503-5473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number14016801-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPHYSICIANASSISTANT
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: