Provider Demographics
NPI:1124006143
Name:GUSTAFSON, LYNN K (DPM)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:K
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1421 PREMIERE DR
Practice Address - Street 2:MANKATO CLINIC @ WICKERSHAM CAMPUS
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN492213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
937961OtherMEDICAID (IOWA)
2700674OtherMEDICA (MN)
1M845GUOtherBCBS (MN)
115542OtherUCARE (MN)
MN704325200Medicaid
1753435OtherAMERICA'S PPO (MN)
HP26296OtherHEALTH PARTNERS (MN)
480018263OtherRR MEDICARE
NA2951011002OtherPREFERRED ONE (MN)
HP26296OtherHEALTH PARTNERS (MN)
115542OtherUCARE (MN)