=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164573374
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARGARET SORRELLS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2007
-----------------------------------------------------
Last Update Date | 10/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4309 W MEDICAL CENTER DR STE B300
-----------------------------------------------------
City | MCHENRY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-759-4224
-----------------------------------------------------
Fax | 815-363-0136
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4309 W MEDICAL CENTER DR STE B300
-----------------------------------------------------
City | MCHENRY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60050-8440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-759-4224
-----------------------------------------------------
Fax | 815-363-0136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 085-000756
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------