Provider Demographics
NPI:1932754496
Name:GUSTAVSEN, EVAN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:GUSTAVSEN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 W WYNDEMERE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1359
Mailing Address - Country:US
Mailing Address - Phone:208-283-9592
Mailing Address - Fax:
Practice Address - Street 1:5909 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3039
Practice Address - Country:US
Practice Address - Phone:208-343-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID6426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist