Provider Demographics
NPI:1659701696
Name:BURKE, JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 FORT HENRY DR
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37663-2617
Mailing Address - Country:US
Mailing Address - Phone:423-224-3950
Mailing Address - Fax:423-224-3959
Practice Address - Street 1:4600 FORT HENRY DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37663
Practice Address - Country:US
Practice Address - Phone:423-224-3950
Practice Address - Fax:423-224-3959
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004691363A00000X
TN2436363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1659701696Medicaid
TNQ003860Medicaid
TN103I977753Medicare PIN
TNQ003860Medicaid
VAVVF296AMedicare PIN