Provider Demographics
NPI:1114400611
Name:CARR, JORDAN DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:DAVID
Last Name:CARR
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 1:183 FITZGERALD RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN SPRINGS
Mailing Address - State:VT
Mailing Address - Zip Code:05757-4119
Mailing Address - Country:US
Mailing Address - Phone:802-558-7466
Mailing Address - Fax:
Practice Address - Street 1:278 VT 149
Practice Address - Street 2:
Practice Address - City:WEST PAWLET
Practice Address - State:VT
Practice Address - Zip Code:05775-9798
Practice Address - Country:US
Practice Address - Phone:802-645-0580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031401363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant