Provider Demographics
NPI:1073651477
Name:GUSTAFSON, AARON (LMT)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 SE 26TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1288
Mailing Address - Country:US
Mailing Address - Phone:503-407-6046
Mailing Address - Fax:
Practice Address - Street 1:2700 SE 26TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1288
Practice Address - Country:US
Practice Address - Phone:503-407-6046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR7401225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist