Provider Demographics
NPI:1306826938
Name:JENSEN, PETER MERRILL (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MERRILL
Last Name:JENSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 HILLTOP DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5857
Mailing Address - Country:US
Mailing Address - Phone:307-382-4114
Mailing Address - Fax:307-382-4131
Practice Address - Street 1:1208 HILLTOP DR
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5857
Practice Address - Country:US
Practice Address - Phone:307-382-4114
Practice Address - Fax:307-382-4131
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5692A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110943000Medicaid
G10054Medicare UPIN
WYW307016Medicare ID - Type Unspecified