Provider Demographics
NPI:1104274802
Name:JORDAN, ELISE (PA-C)
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:JORDAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:MANIGUET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:FILE NO 749733
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 SYCAMORE AVE STE 270
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-7852
Practice Address - Country:US
Practice Address - Phone:760-598-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant