Provider Demographics
NPI:1619602380
Name:SANDUSKY, JOHN JORDAN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JORDAN
Last Name:SANDUSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9314 BUCKBOARD DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45458-3796
Mailing Address - Country:US
Mailing Address - Phone:614-935-7863
Mailing Address - Fax:
Practice Address - Street 1:9314 BUCKBOARD DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45458-3796
Practice Address - Country:US
Practice Address - Phone:614-935-7863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.416152163W00000X
OH144394367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse