Provider Demographics
NPI:1417963588
Name:JENSEN, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:JENSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 STEVENSON RD
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:NY
Mailing Address - Zip Code:12993-2219
Mailing Address - Country:US
Mailing Address - Phone:518-962-2777
Mailing Address - Fax:
Practice Address - Street 1:3384 STATE ROUTE 22
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-5305
Practice Address - Country:US
Practice Address - Phone:518-643-8008
Practice Address - Fax:518-643-8090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA1037Medicare ID - Type Unspecified
NYP33012Medicare UPIN