Basic Information
| Provider Information | |||||||||
| NPI: | 1841775855 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TENSEN | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROOPER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10124 W TANGLEWOOD DR | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837097155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085961768 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 380 9TH ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974399470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419977134 | ||||||||
| FaxNumber: | 5419021320 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2018 | ||||||||
| LastUpdateDate: | 12/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA189122 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA163405 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.