Provider Demographics
NPI:1508004706
Name:GUSTAVISON, CASEY L (ANP)
Entity Type:Individual
Prefix:MS
First Name:CASEY
Middle Name:L
Last Name:GUSTAVISON
Suffix:
Gender:F
Credentials:ANP
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 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:409 W OAK ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1464
Practice Address - Country:US
Practice Address - Phone:618-529-4455
Practice Address - Fax:618-351-1287
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008417363L00000X, 363L00000X
IL209.008417363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71002863BOtherCSR
INPENDINGMedicaid
IN71002863AOtherLICENSE
IN71002863BOtherCSR
INPENDINGMedicare PIN