Provider Demographics
NPI:1508503509
Name:FOSTER, JORDAN DAVID (RN)
Entity Type:Individual
Prefix:MR
First Name:JORDAN
Middle Name:DAVID
Last Name:FOSTER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3108 CANTERBURY BLVD APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-3228
Mailing Address - Country:US
Mailing Address - Phone:517-256-3944
Mailing Address - Fax:
Practice Address - Street 1:127 ROMANZA LN
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-0777
Practice Address - Country:US
Practice Address - Phone:517-256-3944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-19
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28252823A163W00000X
IN138955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty