Provider Demographics
NPI:1609543255
Name:GUSTAFSON, TYLER JOSEPH (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:JOSEPH
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 EAST FAIRMOUNT AVE.
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750
Mailing Address - Country:US
Mailing Address - Phone:716-526-0156
Mailing Address - Fax:
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6626
Practice Address - Country:US
Practice Address - Phone:716-969-4235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant