Provider Demographics
NPI:1194170910
Name:SHIVELY, JORDAN TYLER (DO)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:TYLER
Last Name:SHIVELY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8930 W SUNSET RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5013
Mailing Address - Country:US
Mailing Address - Phone:702-228-8834
Mailing Address - Fax:
Practice Address - Street 1:8930 W SUNSET RD STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5013
Practice Address - Country:US
Practice Address - Phone:702-228-8834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
NVDO2821208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program