Provider Demographics
NPI:1629154851
Name:TICHENOR, JEFFERY ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALAN
Last Name:TICHENOR
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 1:1632 MISSOURI AVENUE
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MO
Mailing Address - Zip Code:64836-2032
Mailing Address - Country:US
Mailing Address - Phone:417-358-7600
Mailing Address - Fax:417-358-4103
Practice Address - Street 1:4049 S CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5303
Practice Address - Country:US
Practice Address - Phone:417-890-5550
Practice Address - Fax:417-890-6429
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109829363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOS39181Medicare UPIN