Provider Demographics
NPI:1487642799
Name:JORDAN, DEAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:D
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 NE 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-6227
Mailing Address - Country:US
Mailing Address - Phone:541-754-2700
Mailing Address - Fax:541-754-2707
Practice Address - Street 1:1122 NE 2ND ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-6227
Practice Address - Country:US
Practice Address - Phone:541-754-2700
Practice Address - Fax:541-754-2707
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR133948Medicaid
OR120813Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
ORR86148Medicare UPIN
OR133948Medicaid