Provider Demographics
NPI:1508175266
Name:LENGEL, JORDAN PAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:PAUL
Last Name:LENGEL
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 1:293 BIRDS HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963
Mailing Address - Country:US
Mailing Address - Phone:570-527-0735
Mailing Address - Fax:
Practice Address - Street 1:293 BIRDS HILL RD
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-9535
Practice Address - Country:US
Practice Address - Phone:570-527-0735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA194908KAGMedicare PIN