Provider Demographics
NPI:1083009120
Name:GUSTAFSON, ERIC ROBERT (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:ROBERT
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 UNION ST
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27855-2031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PL
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:NC
Practice Address - Zip Code:27855-1855
Practice Address - Country:US
Practice Address - Phone:252-398-6291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19852255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer