Basic Information
| Provider Information | |||||||||
| NPI: | 1023129996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | BLAINE | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1134 W HWY 60 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851732647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206892423 | ||||||||
| FaxNumber: | 9284253859 | ||||||||
| Practice Location | |||||||||
| Address1: | 1134 W HWY 60 | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852732647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206892423 | ||||||||
| FaxNumber: | 5206895237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2322 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 507147 | 05 | AZ | MEDICAID | Z69075 | 01 | AZ | PTAN | OTHER |