Healthcare Provider Details

I. General information

NPI: 1770389660
Provider Name (Legal Business Name): TYLER QUINN JORDAN EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 02/21/2025
Certification Date: 02/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 517
SAN JUAN BAUTISTA CA
95045-0517
US

IV. Provider business mailing address

PO BOX 517
SAN JUAN BAUTISTA CA
95045-0517
US

V. Phone/Fax

Practice location:
  • Phone: 831-673-9255
  • Fax:
Mailing address:
  • Phone: 831-673-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberE196203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: