Provider Demographics
NPI:1922019124
Name:GUSTAFSON, MARY DOBRY (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DOBRY
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY RD
Mailing Address - Street 2:DORN VETERAN HOSPITAL
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1638
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:
Practice Address - Street 1:DORN VETERANS ADMINISTRATION
Practice Address - Street 2:6439 GARNER'S FERRY ROAD
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC127363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ06843Medicare UPIN