Provider Demographics
NPI:1629522925
Name:TINNELL, JORDAN WESLEY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:WESLEY
Last Name:TINNELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4130 DUTCHMANS LN
Mailing Address - Street 2:STE. 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4713
Mailing Address - Country:US
Mailing Address - Phone:502-897-1794
Mailing Address - Fax:502-238-1286
Practice Address - Street 1:4130 DUTCHMANS LN
Practice Address - Street 2:STE. 300
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4713
Practice Address - Country:US
Practice Address - Phone:502-897-1794
Practice Address - Fax:502-238-1286
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN99077113A363A00000X, 363AM0700X, 363AS0400X
KYTC492363A00000X, 363AM0700X, 363AS0400X
IN10002178A363A00000X, 363AM0700X, 363AS0400X
KYPA2174363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100415730Medicaid
IN300008427Medicaid
KYK209790Medicare PIN