Provider Demographics
NPI:1538666268
Name:SORENSON, ERIC LUTHER (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:LUTHER
Last Name:SORENSON
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 1:929 SW SIMPSON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3599
Mailing Address - Country:US
Mailing Address - Phone:541-389-7741
Mailing Address - Fax:541-278-8375
Practice Address - Street 1:929 SW SIMPSON AVE STE 300
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3599
Practice Address - Country:US
Practice Address - Phone:541-389-7741
Practice Address - Fax:541-278-8375
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA190165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA190165OtherSTATE LICENSE