Provider Demographics
NPI:1952069403
Name:GUSTAFSON, BRANDON JAMES
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:GUSTAFSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10220 PALM ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5139
Mailing Address - Country:US
Mailing Address - Phone:763-439-0947
Mailing Address - Fax:
Practice Address - Street 1:228 WIECKING CTR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6062
Practice Address - Country:US
Practice Address - Phone:507-389-1866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer