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General NPI Number Information
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NPI Number | 1679608038
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Entity Type | Individual
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Provider Name | PETER JAY IENATSCH PA
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Gender | Male
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Dates
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Enumeration Date | 02/23/2007
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Last Update Date | 12/05/2024
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Provider Practice Location Address
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Address Line | 2610 TENDERFOOT HILL ST
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City | COLORADO SPRINGS
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State | CO
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Zip | 80906-3981
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Country | US
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Telephone | 719-522-1133
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 35380
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City | LAS VEGAS
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State | NV
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Zip | 89133-5380
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Country | US
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Telephone | 719-463-5600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA05044
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA0004947
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License Number State | CO
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