Provider Demographics
NPI:1750965034
Name:PORUBAN, JORDAN ROCHELLE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ROCHELLE
Last Name:PORUBAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 LEE ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:PA
Mailing Address - Zip Code:15946-1114
Mailing Address - Country:US
Mailing Address - Phone:814-418-7399
Mailing Address - Fax:
Practice Address - Street 1:223 LEE ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:PA
Practice Address - Zip Code:15946-1114
Practice Address - Country:US
Practice Address - Phone:814-418-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner