Provider Demographics
NPI:1255971578
Name:VILLA, JORDAN D (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:D
Last Name:VILLA
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 1:946 E DENTON LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2674
Mailing Address - Country:US
Mailing Address - Phone:602-723-5111
Mailing Address - Fax:
Practice Address - Street 1:4566 E INVERNESS AVE STE 208
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4634
Practice Address - Country:US
Practice Address - Phone:480-993-1300
Practice Address - Fax:480-212-1027
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty