Provider Demographics
NPI:1295368967
Name:GUSTAD, OLIN VERNON
Entity Type:Individual
Prefix:
First Name:OLIN
Middle Name:VERNON
Last Name:GUSTAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14355 S CAMINO VALLADO
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8437
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HIGHWAY 86 & TOPAWA RD
Practice Address - Street 2:
Practice Address - City:SELLS
Practice Address - State:AZ
Practice Address - Zip Code:85746
Practice Address - Country:US
Practice Address - Phone:520-383-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN183767163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical