Provider Demographics
NPI:1083075980
Name:GASTELUM, CHRISTOPHER G SR
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:G
Last Name:GASTELUM
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 VICTOR HUGO LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-8231
Mailing Address - Country:US
Mailing Address - Phone:702-793-8414
Mailing Address - Fax:
Practice Address - Street 1:1748 VICTOR HUGO LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-8231
Practice Address - Country:US
Practice Address - Phone:702-793-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2016-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16-154246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant