=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750416582
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMINIC LOUIS SORRENTINO JR. PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 10/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8648 E STATE ROAD 70
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-732-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8648 E STATE ROAD 70
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-3785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-732-1209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | PA9101611
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------