Provider Demographics
NPI:1922177088
Name:GUSTAFSON, CHRIS (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:
Last Name:GUSTAFSON
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 1:3901 HOYT AVE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4918
Mailing Address - Country:US
Mailing Address - Phone:360-629-1100
Mailing Address - Fax:
Practice Address - Street 1:7205 265TH ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-6221
Practice Address - Country:US
Practice Address - Phone:360-629-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA100000400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q41809Medicare UPIN
8852728Medicare PIN