Provider Demographics
NPI:1902357171
Name:GUSTAVESON, TROY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:
Last Name:GUSTAVESON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 N LA CHOLLA BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3535
Mailing Address - Country:US
Mailing Address - Phone:520-297-0404
Mailing Address - Fax:520-297-0436
Practice Address - Street 1:5910 N LA CHOLLA BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3535
Practice Address - Country:US
Practice Address - Phone:520-297-0404
Practice Address - Fax:520-297-0436
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6477363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical