Provider Demographics
NPI:1144787805
Name:OSTERMAN, JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:OSTERMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5169 S COTTONWOOD ST STE 400
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6769
Mailing Address - Country:US
Mailing Address - Phone:303-931-2731
Mailing Address - Fax:
Practice Address - Street 1:5169 S COTTONWOOD ST STE 400
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6769
Practice Address - Country:US
Practice Address - Phone:303-931-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006153363A00000X
UT11820832-1206363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical