Provider Demographics
NPI:1144560376
Name:JORDAN, LISA MARIE (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:RAZZINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:140 COMMONWEALTH AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-3624
Mailing Address - Country:US
Mailing Address - Phone:978-777-6544
Mailing Address - Fax:
Practice Address - Street 1:140 COMMONWEALTH AVE
Practice Address - Street 2:STE 104
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-3624
Practice Address - Country:US
Practice Address - Phone:978-777-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400200024Medicare UPIN