Provider Demographics
NPI:1891338646
Name:JENIK, ALEXANDER NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:NICHOLAS
Last Name:JENIK
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 1:1510 BISON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-1541
Mailing Address - Country:US
Mailing Address - Phone:719-271-7193
Mailing Address - Fax:
Practice Address - Street 1:2322 S ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80916-2406
Practice Address - Country:US
Practice Address - Phone:719-390-1727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005988363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1163223OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
COPA.0005988OtherSTATE MEDICAL LICENSE NUMBER