Provider Demographics
NPI:1760616759
Name:GUSTAFSON, SUSAN E (CRNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:634 ALPHA DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-2802
Mailing Address - Country:US
Mailing Address - Phone:610-892-8991
Mailing Address - Fax:610-892-8991
Practice Address - Street 1:634 ALPHA DR
Practice Address - Street 2:SUITE 600
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15238-2802
Practice Address - Country:US
Practice Address - Phone:610-892-8991
Practice Address - Fax:610-892-8991
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP010257363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022918120001Medicaid
PA1022918120001Medicaid