Provider Demographics
NPI:1942572409
Name:OLDFATHER, JODI MOONBEAM (CRNA)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:MOONBEAM
Last Name:OLDFATHER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 W MACARTHUR BLVD
Mailing Address - Street 2:DEPARTMENT OF ANESTHESIA
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5642
Mailing Address - Country:US
Mailing Address - Phone:510-752-6238
Mailing Address - Fax:
Practice Address - Street 1:280 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5642
Practice Address - Country:US
Practice Address - Phone:510-752-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-31
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4160367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered