Basic Information
| Provider Information | |||||||||
| NPI: | 1659504694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1475 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503051475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159618448 | ||||||||
| FaxNumber: | 5156439100 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 E SCENIC VALLEY AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501254865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5159618448 | ||||||||
| FaxNumber: | 5156439100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 06/09/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 001999 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.