Provider Demographics
NPI:1982062576
Name:JORDAN, SHANE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:
Last Name:JORDAN
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 1:80 MAIDEN LN STE 900
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-4811
Mailing Address - Country:US
Mailing Address - Phone:917-261-4414
Mailing Address - Fax:917-261-4420
Practice Address - Street 1:80 MAIDEN LN STE 900
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-4811
Practice Address - Country:US
Practice Address - Phone:917-261-4414
Practice Address - Fax:917-261-4420
Is Sole Proprietor?:No
Enumeration Date:2016-02-10
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant