Provider Demographics
NPI:1770212417
Name:SANDEFUR, JACOB DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:DAVID
Last Name:SANDEFUR
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 E N CT
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-3858
Mailing Address - Country:US
Mailing Address - Phone:541-519-0890
Mailing Address - Fax:
Practice Address - Street 1:900 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1387
Practice Address - Country:US
Practice Address - Phone:541-963-8421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN239503163W00000X
OR202214569CRNAPP367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse