Basic Information
| Provider Information | |||||||||
| NPI: | 1629019997 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JORDAN | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976307 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GROVE RD | ||||||||
| Address2: | 2ND FLOOR ANESTHESIA DEPT. | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644557111 | ||||||||
| FaxNumber: | 8644556441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APRN1997 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 20031911 | 01 | SC | SELECT HEALTH GROUP | OTHER | 576007863 | 01 | SC | UHC | OTHER | 20031926 | 01 | SC | INDIVIDUAL SELECT HEALTH | OTHER | 576007863 | 01 | SC | AETNA | OTHER | 576007863BCBS | 01 | SC | BCBS | OTHER | 576007863 | 01 | SC | CIGNA | OTHER | 576007863 | 01 | SC | BLUE CHOICE | OTHER | AN1263 | 05 | SC | MEDICAID |