Provider Demographics
NPI:1770117384
Name:TYSDAL, JORDAN ARLING (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:ARLING
Last Name:TYSDAL
Suffix:
Gender:M
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 1:1804 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-2513
Mailing Address - Country:US
Mailing Address - Phone:218-343-3046
Mailing Address - Fax:
Practice Address - Street 1:3141 CENTENNIAL BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-4094
Practice Address - Country:US
Practice Address - Phone:719-327-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006109363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant