Healthcare Provider Details

I. General information

NPI: 1568911170
Provider Name (Legal Business Name): JAMES MARSHALL JORDAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CAISSON HILL RD
FT RILEY KS
66442-7037
US

IV. Provider business mailing address

650 HUEBNER RD
FORT RILEY KS
66442-4030
US

V. Phone/Fax

Practice location:
  • Phone: 580-919-2835
  • Fax:
Mailing address:
  • Phone: 785-239-7151
  • Fax: 785-240-7438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: