Provider Demographics
NPI:1487278453
Name:EVANS, JORDAN GREGORY (PA-S)
Entity type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:GREGORY
Last Name:EVANS
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:INKOM
Mailing Address - State:ID
Mailing Address - Zip Code:83245-0106
Mailing Address - Country:US
Mailing Address - Phone:208-705-8299
Mailing Address - Fax:
Practice Address - Street 1:CREIGHTON HALL 222 SE 8TH AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123
Practice Address - Country:US
Practice Address - Phone:503-352-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61635363A00000X
390200000X
IDPA-2681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program