Provider Demographics
NPI:1982702239
Name:JORDAN, SAMANTHA M (PA-C, MMS)
Entity Type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:M
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C, MMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8580 SCARBOROUGH DR
Mailing Address - Street 2:SUITE 225
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7583
Mailing Address - Country:US
Mailing Address - Phone:719-531-5400
Mailing Address - Fax:719-531-9545
Practice Address - Street 1:8580 SCARBOROUGH DR
Practice Address - Street 2:SUITE 225
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7583
Practice Address - Country:US
Practice Address - Phone:719-531-5400
Practice Address - Fax:719-531-9545
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2544207N00000X
COPA.0003956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2544OtherSTATE LICENSE
2544OtherAZ STATE LICENSE
AZ69841Medicare PIN
AZ2544OtherSTATE LICENSE
AZZ69841Medicare PIN
AZMJ0781004OtherDEA#