Provider Demographics
NPI:1740236843
Name:JANSEN, SANDRA M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:M
Last Name:JANSEN
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 1:2202 N FORBES BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85745-1412
Mailing Address - Country:US
Mailing Address - Phone:520-872-7265
Mailing Address - Fax:520-872-7929
Practice Address - Street 1:630 N ALVERNON WAY
Practice Address - Street 2:STE 371
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-1843
Practice Address - Country:US
Practice Address - Phone:520-319-3956
Practice Address - Fax:520-319-3913
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1476363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ115903OtherMEDICARE PTAN
AZ196601Medicaid
AZ196601Medicaid