Healthcare Provider Details

I. General information

NPI: 1295085652
Provider Name (Legal Business Name): JORDAN NICOLE GLADSTONE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ATWELL RD
COOPERSTOWN NY
13326
US

IV. Provider business mailing address

1 ATWELL RD
COOPERSTOWN NY
13326-1394
US

V. Phone/Fax

Practice location:
  • Phone: 607-547-3456
  • Fax:
Mailing address:
  • Phone: 607-547-3034
  • Fax: 607-547-7732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-03757
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034759
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: