Basic Information
| Provider Information | |||||||||
| NPI: | 1124006143 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1421 PREMIERE DR | ||||||||
| Address2: | MANKATO CLINIC @ WICKERSHAM CAMPUS | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 492 | MN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 937961 | 01 | MEDICAID (IOWA) | OTHER | 2700674 | 01 | MEDICA (MN) | OTHER | 1M845GU | 01 | BCBS (MN) | OTHER | 115542 | 01 | UCARE (MN) | OTHER | 704325200 | 05 | MN | MEDICAID | 1753435 | 01 | AMERICA'S PPO (MN) | OTHER | HP26296 | 01 | HEALTH PARTNERS (MN) | OTHER | 480018263 | 01 | RR MEDICARE | OTHER | NA2951011002 | 01 | PREFERRED ONE (MN) | OTHER |