Provider Demographics
NPI:1932472966
Name:GUSTAFSON, KARIN ELIZABETH (CNM)
Entity Type:Individual
Prefix:
First Name:KARIN
Middle Name:ELIZABETH
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1909
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-283-7354
Practice Address - Street 1:1211 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-283-7354
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178533-030163W00000X
WI148938-32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1932472966Medicaid