Provider Demographics
NPI:1144302803
Name:JORDAN, WILLIAM J (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:JORDAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 S MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-3546
Mailing Address - Country:US
Mailing Address - Phone:517-394-3175
Mailing Address - Fax:517-394-7453
Practice Address - Street 1:839 S PUTNAM ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-1623
Practice Address - Country:US
Practice Address - Phone:517-655-3515
Practice Address - Fax:855-476-0189
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0N61290008OtherMEDICARE PLUS BLUE-MEDICARE ADVANTAGE
MI1153313120OtherBLUE CROSS BLUE SHIELD
0N61290008OtherMEDICARE PLUS BLUE-MEDICARE ADVANTAGE