Provider Demographics
NPI:1164433827
Name:SORENSEN, RUSTIN G (PA-C)
Entity Type:Individual
Prefix:
First Name:RUSTIN
Middle Name:G
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 BLUEWATER BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-897-8081
Mailing Address - Fax:850-897-3846
Practice Address - Street 1:1950 BLUEWATER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578
Practice Address - Country:US
Practice Address - Phone:850-897-8081
Practice Address - Fax:850-897-3846
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101453363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL970023871OtherRRMC
FL970023871OtherRRMC
FLE6611ZMedicare PIN