Provider Demographics
NPI:1093805467
Name:JENSEN, WILLIAM J (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
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 1:215 E HAWAII AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6099
Mailing Address - Country:US
Mailing Address - Phone:208-463-3000
Mailing Address - Fax:208-463-3043
Practice Address - Street 1:875 S VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7552
Practice Address - Country:US
Practice Address - Phone:208-463-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-618363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1253103Medicare Oscar/Certification
NVQ25275Medicare UPIN
IDDA3027Medicare Oscar/Certification
ID138505Medicare Oscar/Certification
NVQ25275Medicare UPIN
IDDA3027Medicare Oscar/Certification
ID807582300Medicaid
ID138505Medicare Oscar/Certification