Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 488 | TX |
Y | 222Z00000X | Podiatrist | 488 | TX |
N | 224P00000X | Prosthetist | 488 | TX |
NPI | 1396177069 |
---|---|
Provider Name | Stacey Lynn Jordan |
First Address | Amarillo, TX 79116-3702 |
Second Address | Amarillo, TX 79106-8555 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2013 |
Last Update Date | 05/08/2013 |