Provider Demographics
NPI:1558015099
Name:GUSTAFSON, LEIGH ANNE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANNE
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2678 KERRISDALE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5719
Mailing Address - Country:US
Mailing Address - Phone:541-601-8569
Mailing Address - Fax:
Practice Address - Street 1:827 SPRING ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6104
Practice Address - Country:US
Practice Address - Phone:541-732-7600
Practice Address - Fax:541-732-7601
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202201187NP-PP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care