Provider Demographics
NPI:1871881094
Name:SORUM, NATHANAEL P (PT)
Entity type:Individual
Prefix:MR
First Name:NATHANAEL
Middle Name:P
Last Name:SORUM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:5055 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1006
Mailing Address - Country:US
Mailing Address - Phone:414-429-3030
Mailing Address - Fax:414-892-5745
Practice Address - Street 1:20700 WATERTOWN RD STE 100
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-1800
Practice Address - Country:US
Practice Address - Phone:414-540-8821
Practice Address - Fax:414-892-5745
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI11704-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11704-24OtherDTP