Provider Demographics
NPI:1942224993
Name:DOURMASHKIN, JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:DOURMASHKIN
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 1:56 ARTHUR PL
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1703
Mailing Address - Country:US
Mailing Address - Phone:914-376-9554
Mailing Address - Fax:914-376-9554
Practice Address - Street 1:56 ARTHUR PL
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1703
Practice Address - Country:US
Practice Address - Phone:914-376-9554
Practice Address - Fax:914-376-9554
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001590363A00000X
NY008492363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001819Medicare ID - Type Unspecified
P49699Medicare UPIN