Provider Demographics
NPI:1598018137
Name:SORENSEN, NISSA R (PTA)
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:R
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 WOODS CT
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-2915
Mailing Address - Country:US
Mailing Address - Phone:541-386-9511
Mailing Address - Fax:866-860-8070
Practice Address - Street 1:1627 WOODS CT
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-2915
Practice Address - Country:US
Practice Address - Phone:541-386-9511
Practice Address - Fax:866-860-8070
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8735225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant