Provider Demographics
NPI:1659504694
Name:GUSTAFSON, MEGAN J (PA)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:J
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PA
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 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-961-8448
Mailing Address - Fax:515-643-9100
Practice Address - Street 1:307 E SCENIC VALLEY AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:IA
Practice Address - Zip Code:50125-4865
Practice Address - Country:US
Practice Address - Phone:515-961-8448
Practice Address - Fax:515-643-9100
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant