Healthcare Provider Details

I. General information

NPI: 1073027389
Provider Name (Legal Business Name): JORDAN JOSEPH CORMIER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 11/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 DESOTO ST
IDAHO FALLS ID
83404-7570
US

IV. Provider business mailing address

2330 DESOTO ST
IDAHO FALLS ID
83404-7570
US

V. Phone/Fax

Practice location:
  • Phone: 208-552-4909
  • Fax: 208-522-6101
Mailing address:
  • Phone: 208-552-4909
  • Fax: 208-522-6101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberPA1568
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberPA-1568
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: