1558015099 NPI number — LEIGH ANNE GUSTAFSON AGACNP-BC

Table of content: LEIGH ANNE GUSTAFSON AGACNP-BC (NPI 1558015099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558015099 NPI number — LEIGH ANNE GUSTAFSON AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUSTAFSON
Provider First Name:
LEIGH
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558015099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2678 KERRISDALE RIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-5719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-601-8569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
827 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-6104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-732-7600
Provider Business Practice Location Address Fax Number:
541-732-7601
Provider Enumeration Date:
02/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  202201187NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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