Provider Demographics
NPI:1508578220
Name:SORRELLS, CHARLES CONNOR (CAA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CONNOR
Last Name:SORRELLS
Suffix:
Gender:M
Credentials:CAA
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Other - Credentials:
Mailing Address - Street 1:PO BOX 78838
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-0838
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1710 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1033
Practice Address - Country:US
Practice Address - Phone:317-528-4800
Practice Address - Fax:317-865-1479
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN75000119A367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant