Provider Demographics
NPI:1699447615
Name:WYATT, JORDAN CAGE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JORDAN
Middle Name:CAGE
Last Name:WYATT
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 1:2449 HOSPITAL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-1910
Mailing Address - Country:US
Mailing Address - Phone:318-212-7960
Mailing Address - Fax:318-212-7965
Practice Address - Street 1:2449 HOSPITAL DR STE 300
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-1910
Practice Address - Country:US
Practice Address - Phone:318-212-7960
Practice Address - Fax:318-212-7965
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA328850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant