Healthcare Provider Details

I. General information

NPI: 1104310929
Provider Name (Legal Business Name): TYLER KENNETH SORENSEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 24TH ST S
WISCONSIN RAPIDS WI
54494-1906
US

IV. Provider business mailing address

140 24TH ST S
WISCONSIN RAPIDS WI
54494-1906
US

V. Phone/Fax

Practice location:
  • Phone: 715-424-1881
  • Fax:
Mailing address:
  • Phone: 715-424-1881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO4400
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: