Provider Demographics
NPI:1538112610
Name:JENSEN, SCOT BRAM (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOT
Middle Name:BRAM
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-2650
Mailing Address - Fax:801-387-2655
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 3490
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-2650
Practice Address - Fax:801-387-2655
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4783572-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q71913Medicare UPIN