Provider Demographics
NPI:1194879510
Name:SORACE, EDWARD F (PA-C)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:F
Last Name:SORACE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 RING RD
Mailing Address - Street 2:WORKWELL
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-4900
Mailing Address - Country:US
Mailing Address - Phone:270-706-5621
Mailing Address - Fax:270-706-5329
Practice Address - Street 1:1111 RING RD
Practice Address - Street 2:WORKWELL
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-4900
Practice Address - Country:US
Practice Address - Phone:270-706-5621
Practice Address - Fax:270-706-5329
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPAC15363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPAC15OtherKBML LICENSE NUMBER
1004764OtherNCCPA
00615OtherAAPA NUMBER