Provider Demographics
NPI:1578933693
Name:BEAVERSON, JORDAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BEAVERSON
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 1:27853 LUKE ST
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-4066
Mailing Address - Country:US
Mailing Address - Phone:239-872-5739
Mailing Address - Fax:
Practice Address - Street 1:625 9TH ST N
Practice Address - Street 2:SUITE 201
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-8143
Practice Address - Country:US
Practice Address - Phone:239-261-2000
Practice Address - Fax:239-261-2266
Is Sole Proprietor?:No
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant