MEDICARE: BRYAN W SORENSON

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	172A00000X	Driver

General Provider Information

NPI Number	:	1760064836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN W SORENSON

Provider Business Mailing Address
First Line	:	6113 MAPLE VALLEY DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-7657
Country	:	US
Telephone Number	:	701-200-7738
Fax Number	:

Provider Business Practice Location Address
First Line	:	6113 MAPLE VALLEY DR S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-7657
Country	:	US
Telephone Number	:	701-232-3322
Fax Number	:

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

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	04/27/2021

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Directions to “ BRYAN W SORENSON ” Practice Location

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