Provider Demographics
NPI:1033291596
Name:LAUSTSEN, GARY ROBERT (FNP, PHD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROBERT
Last Name:LAUSTSEN
Suffix:
Gender:M
Credentials:FNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2807
Mailing Address - Country:US
Mailing Address - Phone:541-962-3132
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2807
Practice Address - Country:US
Practice Address - Phone:541-962-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2012-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650119NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS81057Medicare UPIN