Provider Demographics
NPI:1407815970
Name:SORESTAD, MYRON P (RPT)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:P
Last Name:SORESTAD
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4141 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-6021
Mailing Address - Country:US
Mailing Address - Phone:605-399-9565
Mailing Address - Fax:605-399-9584
Practice Address - Street 1:4141 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-6021
Practice Address - Country:US
Practice Address - Phone:605-399-9565
Practice Address - Fax:605-399-9584
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2011-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0562225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5831210Medicaid
SD0562OtherDAKOTACARE
SD22924OtherSANFORD HEALTH
SD4998878OtherWELLMARK
SD650012496Medicare PIN
SD0562OtherDAKOTACARE