Provider Demographics
NPI:1760430078
Name:SORENSON-LAVALLEY, KAREN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:SORENSON-LAVALLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:LAVALLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:225 CHURCH ST
Mailing Address - Street 2:DEAN MEDICAL CENTER
Mailing Address - City:STOUGHTON
Mailing Address - State:WI
Mailing Address - Zip Code:53589-1801
Mailing Address - Country:US
Mailing Address - Phone:608-877-2700
Mailing Address - Fax:608-877-2726
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:DEAN MEDICAL CENTER
Practice Address - City:STOUGHTON
Practice Address - State:WI
Practice Address - Zip Code:53589-1801
Practice Address - Country:US
Practice Address - Phone:608-877-2700
Practice Address - Fax:608-877-2726
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI381-023363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42909700Medicaid
WI3990OtherDEAN HEALTH INSURANCE
WIK400162886Medicare PIN
WI050574150Medicare PIN
WI3990OtherDEAN HEALTH INSURANCE
R97859Medicare UPIN