Basic Information
| Provider Information | |||||||||
| NPI: | 1891717450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SENN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
| FaxNumber: | 7012393719 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581022417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012393700 | ||||||||
| FaxNumber: | 7012393719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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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 | 363AM0700X | PAC0296 | ND | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PAC0296 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 866438200 | 05 | MN | MEDICAID |