Provider Demographics
NPI:1285652867
Name:JENSEN, TATE ALAN (PAC)
Entity Type:Individual
Prefix:
First Name:TATE
Middle Name:ALAN
Last Name:JENSEN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 W 3500 S
Mailing Address - Street 2:
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-1851
Mailing Address - Country:US
Mailing Address - Phone:801-250-9638
Mailing Address - Fax:801-250-3204
Practice Address - Street 1:8211 W 3500 S
Practice Address - Street 2:
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-1851
Practice Address - Country:US
Practice Address - Phone:801-250-9638
Practice Address - Fax:801-250-3204
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346683-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q58686Medicare UPIN