Provider Demographics
NPI:1336514033
Name:MONTEVERDI, JORDAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:
Last Name:MONTEVERDI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:JORDAN
Other - Middle Name:
Other - Last Name:MONTEVERDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 6210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-6210
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-505-2259
Practice Address - Street 1:407 S SCHWARTZ AVE STE 202
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5925
Practice Address - Country:US
Practice Address - Phone:505-609-6770
Practice Address - Fax:505-609-6775
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2015-0100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant