Healthcare Provider Details

I. General information

NPI: 1942481742
Provider Name (Legal Business Name): RYAN MICHELLE JORDAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 VAN NUYS BLVD 505
SHERMAN OAKS CA
91403-1801
US

IV. Provider business mailing address

4955 VAN NUYS BLVD 505
SHERMAN OAKS CA
91403-1801
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-5500
  • Fax: 818-986-5503
Mailing address:
  • Phone: 818-986-5500
  • Fax: 818-986-5503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18735
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: