Provider Demographics
NPI:1740159060
Name:JORDAN, BLAKE NELSON (PA-C)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:NELSON
Last Name:JORDAN
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 1:892 S 30 E
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-5305
Mailing Address - Country:US
Mailing Address - Phone:435-227-6263
Mailing Address - Fax:
Practice Address - Street 1:1784 UINTA WAY STE E
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7669
Practice Address - Country:US
Practice Address - Phone:435-604-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical