Provider Demographics
NPI:1578002077
Name:JORDAN, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JORDAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3067
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-3067
Mailing Address - Country:US
Mailing Address - Phone:530-751-4784
Mailing Address - Fax:530-751-4906
Practice Address - Street 1:1531 PLUMAS CT
Practice Address - Street 2:SUITE B
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-2966
Practice Address - Country:US
Practice Address - Phone:530-751-4900
Practice Address - Fax:530-751-4901
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant