Provider Demographics
NPI:1306243191
Name:DASILVA, JORDAN RAE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JORDAN
Middle Name:RAE
Last Name:DASILVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 ORA AVE SE UNIT B
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-2145
Mailing Address - Country:US
Mailing Address - Phone:774-688-9180
Mailing Address - Fax:
Practice Address - Street 1:631 PROFESSIONAL DR STE 360
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-3370
Practice Address - Country:US
Practice Address - Phone:678-312-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA363A00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant