MEDICARE: MICHAEL B JORGENSEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	01693T	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IA01B9	OTHER		JOHN DEERE HEALTH

General Provider Information

NPI Number	:	1457302101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL B JORGENSEN PA-C

Provider Business Mailing Address
First Line	:	450 BROADWAY ST
Second Line	:	PAVILION A, 2ND FLOOR
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-3132
Country	:	US
Telephone Number	:	818-621-6612
Fax Number	:	650-723-5643

Provider Business Practice Location Address
First Line	:	450 BROADWAY ST
Second Line	:	PAVILION A, 2ND FLOOR
City	:	REDWOOD CITY
State	:	CA
Zip	:	94063-3132
Country	:	US
Telephone Number	:	818-621-6612
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	05/26/2009

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