Provider Demographics
NPI:1255684106
Name:GUSTAFSON, KERIANNE ERIKA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KERIANNE
Middle Name:ERIKA
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5153 ABBOTT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-2144
Mailing Address - Country:US
Mailing Address - Phone:628-252-8937
Mailing Address - Fax:
Practice Address - Street 1:3801 MIRANDA AVE # 112
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1290
Practice Address - Country:US
Practice Address - Phone:650-493-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant