Provider Demographics
NPI:1891176434
Name:GUSTAFSON, MELISSA
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:SETTAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:1219 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-2728
Mailing Address - Country:US
Mailing Address - Phone:856-981-3524
Mailing Address - Fax:
Practice Address - Street 1:700 WELCH RD
Practice Address - Street 2:SUITE 301
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1502
Practice Address - Country:US
Practice Address - Phone:650-497-9063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002210363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics