Provider Demographics
NPI:1407072341
Name:JORDAN, TIFFANY B (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:B
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:23471 WALDEN CENTER DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-5016
Mailing Address - Country:US
Mailing Address - Phone:239-596-9337
Mailing Address - Fax:239-596-9466
Practice Address - Street 1:2235 VENETIAN COURT
Practice Address - Street 2:SUITE 1
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34109-8728
Practice Address - Country:US
Practice Address - Phone:239-596-9337
Practice Address - Fax:239-596-9466
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2020-07-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPT224402251S0007X
FLAL19922083S0010X
FLPA9106038363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFH622Y K4948OtherMEDICARE