Provider Demographics
NPI:1063669778
Name:GUSTAFSON, AMBER JOY (PA)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:JOY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 US 2 & 41
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BARK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49807
Mailing Address - Country:US
Mailing Address - Phone:906-466-2000
Mailing Address - Fax:906-466-2067
Practice Address - Street 1:2845 US 2 & 41
Practice Address - Street 2:SUITE 201
Practice Address - City:BARK RIVER
Practice Address - State:MI
Practice Address - Zip Code:49807
Practice Address - Country:US
Practice Address - Phone:906-466-2000
Practice Address - Fax:906-466-2067
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005343363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAG005343OtherBLUE CROSS BLUE SHIELD
MIAG005343OtherBLUE CROSS BLUE SHIELD