Provider Demographics
NPI:1649440520
Name:JORDAN, MICHELLE LYNNE (PA-C)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LYNNE
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1528
Mailing Address - Fax:813-255-2818
Practice Address - Street 1:11601 SHELDON RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-4306
Practice Address - Country:US
Practice Address - Phone:813-324-6630
Practice Address - Fax:813-926-1500
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104461363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107119000Medicaid