Provider Demographics
NPI:1588647374
Name:SORRENTINO, RANDALL JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:JAMES
Last Name:SORRENTINO
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 1:13203 N 103RD AVE STE H5
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3032
Mailing Address - Country:US
Mailing Address - Phone:623-777-4747
Mailing Address - Fax:
Practice Address - Street 1:13203 N 103RD AVE STE H5
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3032
Practice Address - Country:US
Practice Address - Phone:623-777-4747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7209350001332B00000X
AZ7045160001332B00000X
AZ7047150001332B00000X
AZ7046960001332B00000X
AZ7629170001332B00000X
AZ7057360001332B00000X
AZ7034950001332B00000X
NJ25MP00072600363A00000X
AZ3649363A00000X
363A00000X
NC0010-08611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3649OtherARIZONA LICENSE
AZ283684Medicaid