Healthcare Provider Details

I. General information

NPI: 1851821896
Provider Name (Legal Business Name): JORDAN NICOLE SURRUSCO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JORDAN NICOLE CONNELLY

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-3003
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4300
  • Fax:
Mailing address:
  • Phone: 206-520-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60883471
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: