Provider Demographics
NPI:1124526462
Name:LIRA, JORDYN MARISA (PA)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:MARISA
Last Name:LIRA
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:JORDYN
Other - Middle Name:MARISA
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC/LAT, PA
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:701 DELLWOOD ST S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1920
Practice Address - Country:US
Practice Address - Phone:763-689-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
MN15242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program