Provider Demographics
NPI:1093000341
Name:GUSTAFSON, LISA ANNE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR
Mailing Address - Street 2:ROOM HC029, MC:5277
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-724-0385
Mailing Address - Fax:650-497-7056
Practice Address - Street 1:300 PASTEUR DR
Practice Address - Street 2:ROOM HC029
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-724-0385
Practice Address - Fax:650-497-7056
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18044363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner