Provider Demographics
NPI:1174509103
Name:GUSTAFSON, JULIA A (NP)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:A
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 1:13989 STANTON CIR
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8641
Mailing Address - Country:US
Mailing Address - Phone:209-588-5584
Mailing Address - Fax:209-588-0911
Practice Address - Street 1:12811 COVEY CIR
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5935
Practice Address - Country:US
Practice Address - Phone:209-588-8840
Practice Address - Fax:209-588-0911
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP5485363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23914Medicare ID - Type Unspecified