Provider Demographics
NPI:1497945091
Name:SORENSEN, ERIC LEONARD (NP)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LEONARD
Last Name:SORENSEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N 200 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:412 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4038
Practice Address - Country:US
Practice Address - Phone:435-713-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167553363LA2100X
FLARNP9308320363LF0000X
UT5662905-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002499500Medicaid
DQ733ZOtherMEDICARE PTAN
VA1497945091Medicaid