Provider Demographics
NPI:1770250094
Name:SOSA, GUSTAVO ALEXANDER
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALEXANDER
Last Name:SOSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8550 GREENWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-4715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8550 GREENWAY BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-4715
Practice Address - Country:US
Practice Address - Phone:916-612-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program