MEDICARE: ALLYSON EGGERTZ SORENSEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-03314	NC
2	363A00000X	Physician Assistant	8350084-1206	UT

General Provider Information

NPI Number	:	1689948176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLYSON EGGERTZ SORENSEN PA-C

Provider Business Mailing Address
First Line	:	3730 WEST 4700 SOUTH
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84129-3457
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3730 WEST 4700 SOUTH
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84129-3457
Country	:	US
Telephone Number	:	801-213-9200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/29/2012
Last Update Date	:	11/17/2021

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