Provider Demographics
NPI:1134969199
Name:SHOEMAKER, JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:SHOEMAKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:1970 GOLF ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-6908
Practice Address - Country:US
Practice Address - Phone:941-957-1000
Practice Address - Fax:941-951-2117
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122987900Medicaid