Provider Demographics
NPI:1083127203
Name:GUSTAFSON, MAXINE RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:RAE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525 FRANCE AVE S STE 200
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2176
Mailing Address - Country:US
Mailing Address - Phone:952-927-6501
Mailing Address - Fax:952-653-1433
Practice Address - Street 1:6525 FRANCE AVE S STE 200
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2176
Practice Address - Country:US
Practice Address - Phone:952-927-6501
Practice Address - Fax:952-653-1433
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12582363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant