Provider Demographics
NPI:1588624209
Name:SORENSON, MARLYS R (CNP)
Entity Type:Individual
Prefix:
First Name:MARLYS
Middle Name:R
Last Name:SORENSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:3960 COON RAPIDS BLVD NW
Practice Address - Street 2:100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2569
Practice Address - Country:US
Practice Address - Phone:763-236-9400
Practice Address - Fax:763-236-9423
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNRO61749-3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
5000000898Medicare ID - Type Unspecified
S30437Medicare UPIN