Provider Demographics
NPI:1407958614
Name:JORDAN, SUE-ELLEN (CRNA)
Entity Type:Individual
Prefix:
First Name:SUE-ELLEN
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 MEDICAL PARK RD
Mailing Address - Street 2:STE 108
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8529
Mailing Address - Country:US
Mailing Address - Phone:704-662-0877
Mailing Address - Fax:704-662-0875
Practice Address - Street 1:810 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9617
Practice Address - Country:US
Practice Address - Phone:828-326-3809
Practice Address - Fax:828-326-3371
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72862367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052448Medicaid
NC2610162Medicare ID - Type UnspecifiedNC- MEDICARE CRNA