Provider Demographics
NPI:1427322957
Name:WEBER, JORDAN CARL (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:CARL
Last Name:WEBER
Suffix:
Gender:M
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 1:513 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-9675
Mailing Address - Country:US
Mailing Address - Phone:605-384-3418
Mailing Address - Fax:605-384-5240
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3418
Practice Address - Fax:605-384-5240
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX311624601Medicaid