Provider Demographics
NPI:1598843146
Name:TSO, JENNIFER L (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:TSO
Suffix:
Gender:F
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 1:407 S SCHWARTZ AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-5954
Mailing Address - Country:US
Mailing Address - Phone:505-609-6770
Mailing Address - Fax:
Practice Address - Street 1:407 S SCHWARTZ AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5954
Practice Address - Country:US
Practice Address - Phone:505-609-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA20060036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPENDINGMedicaid
NM81427212Medicaid
AZPENDINGMedicaid
AZPENDINGMedicaid
PENDINGMedicare UPIN