Provider Demographics
NPI:1821355694
Name:JORDAN, RANDY SCOTT (RPA)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:SCOTT
Last Name:JORDAN
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3227 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-1801
Mailing Address - Country:US
Mailing Address - Phone:918-728-6194
Mailing Address - Fax:918-664-0267
Practice Address - Street 1:4500 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-5229
Practice Address - Country:US
Practice Address - Phone:918-728-6194
Practice Address - Fax:918-664-0267
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK279995243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant