Basic Information
| Provider Information | |||||||||
| NPI: | 1144302803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5525 S MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489113546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173943175 | ||||||||
| FaxNumber: | 5173947453 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 S PUTNAM ST | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488951623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176553515 | ||||||||
| FaxNumber: | 8554760189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601001389 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0N61290008 | 01 | MEDICARE PLUS BLUE-MEDICARE ADVANTAGE | OTHER | 1153313120 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |