Provider Demographics
NPI:1134139454
Name:JENSEN, SHAYNE RAYMOND (DPM, FACFAS)
Entity Type:Individual
Prefix:DR
First Name:SHAYNE
Middle Name:RAYMOND
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DPM, FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2507 HARRISON AVE
Mailing Address - Street 2:UNIT 201
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4447
Mailing Address - Country:US
Mailing Address - Phone:850-769-0325
Mailing Address - Fax:850-769-4476
Practice Address - Street 1:2201 JENKS AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4531
Practice Address - Country:US
Practice Address - Phone:850-769-0325
Practice Address - Fax:850-769-4476
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2867213E00000X, 213ES0131X, 213ES0103X
FLPO 2867213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45803OtherBLUECROSSBLUESHIELD GROUP
FL65657OtherBLUECROSSBLUESHIEL#
FL061666115OtherTAX ID
FL480035194OtherRR MEDICARE
FLCK8386OtherRR MEDICARE GROUP
FL65657OtherBLUECROSSBLUESHIEL#
FL65657ZMedicare PIN
FLCK8386OtherRR MEDICARE GROUP