MEDICARE: SUSAN MARY JORDAN PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA10005226	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033289012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARY JORDAN PAC

Provider Business Mailing Address
First Line	:	1211 24TH ST
Second Line	:
City	:	ANACORTES
State	:	WA
Zip	:	98221-2562
Country	:	US
Telephone Number	:	360-293-3101
Fax Number	:

Provider Business Practice Location Address
First Line	:	2511 M AVE
Second Line	:	SUITE B
City	:	ANACORTES
State	:	WA
Zip	:	98221-3897
Country	:	US
Telephone Number	:	360-299-4211
Fax Number	:	360-299-4213

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/18/2019

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