Provider Demographics
NPI:1710360938
Name:GUSTAFSON, KEVIN ROSS (CRBA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROSS
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:CRBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6358 SOMBRERO AVE
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:CA
Mailing Address - Zip Code:90630-5326
Mailing Address - Country:US
Mailing Address - Phone:562-225-0025
Mailing Address - Fax:
Practice Address - Street 1:6358 SOMBRERO AVE
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5326
Practice Address - Country:US
Practice Address - Phone:562-225-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2016-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000397367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered