Basic Information
| Provider Information | |||||||||
| NPI: | 1528049335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENSEN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | RUSSELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25488 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004753698 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1433 N 1075 W STE 104 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012981300 | ||||||||
| FaxNumber: | 8012966199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 02/19/2019 | ||||||||
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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 | 2085R0202X | 1816521205 | UT | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00651537 | 01 | UT | RAILROAD MEDICARE | OTHER | 100505791 | 05 | NV | MEDICAID | 807115600 | 05 | ID | MEDICAID | 09899 | 05 | UT | MEDICAID | 120827600 | 05 | WY | MEDICAID | 924432 | 05 | AZ | MEDICAID | P00205744 | 01 | UT | RAILROAD MEDICARE | OTHER |