Provider Demographics
NPI:1598113342
Name:IVERSON, SONNY
Entity Type:Individual
Prefix:
First Name:SONNY
Middle Name:
Last Name:IVERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 POWER INN RD STE 110
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3893
Mailing Address - Country:US
Mailing Address - Phone:916-262-6387
Mailing Address - Fax:
Practice Address - Street 1:3321 POWER INN RD STE 110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3893
Practice Address - Country:US
Practice Address - Phone:916-262-6387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist