Healthcare Provider Details

I. General information

NPI: 1720437551
Provider Name (Legal Business Name): JORDAN ELIZABETH KUDLA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN MUNGOVAN PA

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVE
CLEVELAND OH
44106-1716
US

IV. Provider business mailing address

1215 W 10TH ST APT 602
CLEVELAND OH
44113-1291
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-1000
  • Fax:
Mailing address:
  • Phone: 260-415-9955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004714RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: