Provider Demographics
NPI:1710930185
Name:SORRELL, TANYA R (PHD, NP)
Entity Type:Individual
Prefix:MS
First Name:TANYA
Middle Name:R
Last Name:SORRELL
Suffix:
Gender:F
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 W OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80236-3106
Mailing Address - Country:US
Mailing Address - Phone:303-315-6150
Mailing Address - Fax:303-797-4266
Practice Address - Street 1:255 W 24TH ST
Practice Address - Street 2:SUITE #4
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-8511
Practice Address - Country:US
Practice Address - Phone:928-304-3866
Practice Address - Fax:928-344-1336
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN124885163W00000X
AZAP1834363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ811093OtherAHCCCS
P99290Medicare UPIN
AZ76608Medicare ID - Type UnspecifiedYUMA COUNTY
AZ76609Medicare ID - Type UnspecifiedLA PAZ COUNTY
AZ811093OtherAHCCCS
AZP00326072Medicare ID - Type UnspecifiedRR MEDICARE
AZZ76609Medicare PIN