Provider Demographics
NPI:1558901223
Name:WYRICK, JORDAN MARIE
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARIE
Last Name:WYRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-3703
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2001
Practice Address - Street 1:363 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3703
Practice Address - Country:US
Practice Address - Phone:508-973-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-10
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2336854367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered