Provider Demographics
NPI:1356348858
Name:GUSTAFSON, FAITH A (PA-C)
Entity type:Individual
Prefix:
First Name:FAITH
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:F
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 1:1475 WEBB ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54829-9187
Mailing Address - Country:US
Mailing Address - Phone:717-822-2231
Mailing Address - Fax:715-822-2023
Practice Address - Street 1:1475 WEBB ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:WI
Practice Address - Zip Code:54829-9187
Practice Address - Country:US
Practice Address - Phone:717-822-2231
Practice Address - Fax:715-822-2023
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1677-023363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41981700Medicaid
WI41981700Medicaid
P98429Medicare UPIN