Provider Demographics
NPI:1962185686
Name:KILGORE, JORDAN RYAN (RN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:RYAN
Last Name:KILGORE
Suffix:
Gender:M
Credentials:RN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 BOSTON TOWN RD
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-4536
Mailing Address - Country:US
Mailing Address - Phone:423-243-4812
Mailing Address - Fax:
Practice Address - Street 1:870 BOSTON TOWN RD
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:TN
Practice Address - Zip Code:37327-4536
Practice Address - Country:US
Practice Address - Phone:423-243-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN231456163W00000X
TN34441363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology