Provider Demographics
NPI:1518211051
Name:MAST, JORDAN MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:MICHAEL
Last Name:MAST
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 1:950 EAST HARVARD AVE STE 570
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-7003
Mailing Address - Country:US
Mailing Address - Phone:303-715-9024
Mailing Address - Fax:
Practice Address - Street 1:950 EAST HARVARD AVE STE 570
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-7003
Practice Address - Country:US
Practice Address - Phone:303-715-9024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0003581363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO34073078Medicaid
397170ZJURMedicare PIN