Healthcare Provider Details

I. General information

NPI: 1285230177
Provider Name (Legal Business Name): JORDYN HUDGINS KOEHLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 FAIRVIEW RD STE 808
CHARLOTTE NC
28210-2110
US

IV. Provider business mailing address

6016 KIRKWYND COMMONS DR
CHARLOTTE NC
28278-6660
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1545
  • Fax:
Mailing address:
  • Phone: 704-806-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001010814
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: