Provider Demographics
NPI:1023129996
Name:JENSEN, BLAINE S (PA-C)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:S
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 W HWY 60
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:AZ
Mailing Address - Zip Code:85173-2647
Mailing Address - Country:US
Mailing Address - Phone:520-689-2423
Mailing Address - Fax:928-425-3859
Practice Address - Street 1:1134 W HWY 60
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:AZ
Practice Address - Zip Code:85273-2647
Practice Address - Country:US
Practice Address - Phone:520-689-2423
Practice Address - Fax:520-689-5237
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2322363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ507147Medicaid
AZZ69075OtherPTAN
AZP49154Medicare UPIN
AZ69075Medicare PIN