Provider Demographics
NPI:1073027389
Name:CORMIER, JORDAN JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:JOSEPH
Last Name:CORMIER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 DESOTO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7570
Mailing Address - Country:US
Mailing Address - Phone:208-552-4909
Mailing Address - Fax:208-522-6101
Practice Address - Street 1:2330 DESOTO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7570
Practice Address - Country:US
Practice Address - Phone:208-552-4909
Practice Address - Fax:208-522-6101
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA1568207RS0012X
IDPA-1568207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine