Basic Information
| Provider Information | |||||||||
| NPI: | 1427642479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CORDOVA | ||||||||
| FirstName: | JORDAN | ||||||||
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| Credential: | CAA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2794 S EATON WAY | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802274114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038682360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1488 JESSE JEWELL PKWY SE STE 201 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702199000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2021 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367H00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.