MEDICARE: JORDAN MICHIEL PA-C, MPAS

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	020649	NY

General Provider Information

NPI Number	:	1114466216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN MICHIEL PA-C, MPAS

Provider Business Mailing Address
First Line	:	25 WEICHERS ST
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-3325
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 WEICHERS ST
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-3325
Country	:	US
Telephone Number	:	631-922-4617
Fax Number	:

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

Provider Enumeration Date	:	02/22/2017
Last Update Date	:	02/22/2017

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