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General NPI Number Information
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NPI Number | 1740159060
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Entity Type | Individual
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Provider Name | BLAKE NELSON JORDAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 11/04/2025
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Last Update Date | 11/04/2025
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Provider Practice Location Address
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Address Line | 1784 UINTA WAY STE E
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City | PARK CITY
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State | UT
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Zip | 84098-7669
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Country | US
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Telephone | 435-604-0160
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Fax |
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Provider Business Mailing Address
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Address Line | 892 S 30 E
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City | SALEM
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State | UT
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Zip | 84653-5305
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Country | US
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Telephone | 435-227-6263
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | UT
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