Provider Demographics
NPI:1083727507
Name:GUSTIN, JEAN-LUC LOUIS (PA)
Entity Type:Individual
Prefix:MR
First Name:JEAN-LUC
Middle Name:LOUIS
Last Name:GUSTIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14481 S BUCKNER CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MULINO
Mailing Address - State:OR
Mailing Address - Zip Code:97042-9626
Mailing Address - Country:US
Mailing Address - Phone:503-632-7135
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-643-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical