Provider Demographics
NPI:1336548064
Name:JORDAN, ANTHONY CARROLL (PA-S)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:CARROLL
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 JEFFERSON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-3649
Mailing Address - Country:US
Mailing Address - Phone:360-825-4466
Mailing Address - Fax:
Practice Address - Street 1:1427 JEFFERSON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-3649
Practice Address - Country:US
Practice Address - Phone:360-825-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant