Provider Demographics
NPI:1730950163
Name:LASS, JORDAN LANE (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LANE
Last Name:LASS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2259 BANCROFT BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32833-3804
Mailing Address - Country:US
Mailing Address - Phone:561-512-6749
Mailing Address - Fax:
Practice Address - Street 1:500 WINDERLEY PL STE 115
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7406
Practice Address - Country:US
Practice Address - Phone:407-875-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-15
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9118385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant