Basic Information
| Provider Information | |||||||||
| NPI: | 1528496411 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRAVIS S JENSEN DPM PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1149 | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853801149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235832073 | ||||||||
| FaxNumber: | 6235831099 | ||||||||
| Practice Location | |||||||||
| Address1: | 12361 W BOLA DR | ||||||||
| Address2: | |||||||||
| City: | SURPRISE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853789021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235845626 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2013 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | TRAVIS | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6235832073 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 251822 | 05 | AZ | MEDICAID |