Provider Demographics
NPI:1942481742
Name:JORDAN, RYAN MICHELLE (PA)
Entity Type:Individual
Prefix:MS
First Name:RYAN
Middle Name:MICHELLE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:505
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1801
Mailing Address - Country:US
Mailing Address - Phone:818-986-5500
Mailing Address - Fax:818-986-5503
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:505
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1801
Practice Address - Country:US
Practice Address - Phone:818-986-5500
Practice Address - Fax:818-986-5503
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant