Provider Demographics
NPI:1942016613
Name:DEROWITSCH, JORDON GABRIEL (PA-C)
Entity type:Individual
Prefix:
First Name:JORDON
Middle Name:GABRIEL
Last Name:DEROWITSCH
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 1:1755 RESERVE LN S APT 229
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-3007
Mailing Address - Country:US
Mailing Address - Phone:971-218-3402
Mailing Address - Fax:
Practice Address - Street 1:1600 STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4257
Practice Address - Country:US
Practice Address - Phone:971-218-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR223362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant