Provider Demographics
NPI:1851821896
Name:SURRUSCO, JORDAN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:SURRUSCO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:NICOLE
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-520-5700
Mailing Address - Fax:
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-3003
Practice Address - Country:US
Practice Address - Phone:206-598-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60883471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1851821896Medicaid