1467082743 NPI number — JOSEPH VINCENT JORDAN PA-C

Table of content: JOSEPH VINCENT JORDAN PA-C (NPI 1467082743)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467082743 NPI number — JOSEPH VINCENT JORDAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JORDAN
Provider First Name:
JOSEPH
Provider Middle Name:
VINCENT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467082743
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
713 S MARSHALL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27101-5808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-722-7266
Provider Business Mailing Address Fax Number:
336-201-0538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
964 HIGH HOUSE RD UNIT 4037
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARY
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27513-3574
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-644-0887
Provider Business Practice Location Address Fax Number:
949-862-3679
Provider Enumeration Date:
01/25/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  0110007263 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-12416 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)