Provider Demographics
NPI:1407672629
Name:SHOEMAKER, JORDYN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JORDYN
Middle Name:NICOLE
Last Name:SHOEMAKER
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 1:12711 BUGGVILLE LN
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-4873
Mailing Address - Country:US
Mailing Address - Phone:813-635-6573
Mailing Address - Fax:
Practice Address - Street 1:13470 PARKER COMMONS BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1850
Practice Address - Country:US
Practice Address - Phone:239-415-7576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9119636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty