Provider Demographics
NPI:1598459117
Name:GUSTAVSON, KRISTIN MARGARET (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARGARET
Last Name:GUSTAVSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 SHEPHERD CT APT 111
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1459
Mailing Address - Country:US
Mailing Address - Phone:269-365-4444
Mailing Address - Fax:
Practice Address - Street 1:10625 W NORTH AVE STE 101B
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-877-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant