Basic Information
| Provider Information | |||||||||
| NPI: | 1861012064 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNIDER | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 RIVER BIRCH CT | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236027495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578698169 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6379 CENTER DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2020 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.