Provider Demographics
NPI:1144705898
Name:WISEMAN, JORDAN (PA-C)
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
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 1:1 SUGAR CREEK CENTER BLVD STE 618
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3540
Mailing Address - Country:US
Mailing Address - Phone:832-655-4141
Mailing Address - Fax:713-457-5188
Practice Address - Street 1:1 SUGAR CREEK CENTER BLVD STE 618
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3540
Practice Address - Country:US
Practice Address - Phone:832-655-4141
Practice Address - Fax:713-457-5188
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12258363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8KE886OtherBCBS - UNIVERSAL SURGICAL PARTNERS
TX8KE884OtherBCBS - XCITE SURGICAL
TX8LI002OtherBCBS - BLUE STAR SURGICAL ASSISTANTS LLC
TX8KE885OtherBCBS - UNIVERSAL SURGICAL ASSISTANTS
TXPA12258OtherTEXAS MEDICAL BOARD