Provider Demographics
NPI:1033289012
Name:JORDAN, SUSAN MARY (PAC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARY
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SUE
Other - Middle Name:M
Other - Last Name:MCTAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1211 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-2562
Mailing Address - Country:US
Mailing Address - Phone:360-293-3101
Mailing Address - Fax:
Practice Address - Street 1:2511 M AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-3897
Practice Address - Country:US
Practice Address - Phone:360-299-4211
Practice Address - Fax:360-299-4213
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005226363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ490970Medicaid
AZ490970Medicaid
AZP01360Medicare UPIN