Provider Demographics
NPI:1609929736
Name:GUSTAFSON, GAIL M (CRNP)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:M
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:409 SOUTH FRONT ST
Mailing Address - Street 2:STE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1621
Mailing Address - Country:US
Mailing Address - Phone:717-231-8555
Mailing Address - Fax:717-231-8568
Practice Address - Street 1:205 S FRONT ST
Practice Address - Street 2:4TH FLOOR, BMA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8555
Practice Address - Fax:717-231-8568
Is Sole Proprietor?:No
Enumeration Date:2007-01-20
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PARN644665163W00000X
PASP012635363LA2200X
MDR122422363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103079740Medicaid
PA238743Medicare PIN