Provider Demographics
NPI:1578540498
Name:CHRISTENSEN, JAMES TYLER (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:TYLER
Last Name:CHRISTENSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 CHANNING WAY SUITE 115
Mailing Address - Street 2:PO BOX 1647
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-1647
Mailing Address - Country:US
Mailing Address - Phone:208-535-4130
Mailing Address - Fax:208-535-4125
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-1647
Practice Address - Country:US
Practice Address - Phone:208-535-4130
Practice Address - Fax:208-535-4125
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA402363AM0700X
IDPA-402363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPASQ2OtherBLUE CROSS
ID806420100Medicaid
IDPASQ2OtherBLUE CROSS
ID806420100Medicaid