Basic Information
| Provider Information | |||||||||
| NPI: | 1932472966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | KARIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1211 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082837354 | ||||||||
| Practice Location | |||||||||
| Address1: | 1211 FISH HATCHERY RD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537151909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082528000 | ||||||||
| FaxNumber: | 6082837354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2012 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 178533-030 | WI | N | Nursing Service Providers | Registered Nurse | 367A00000X | 148938-32 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1932472966 | 05 | WI | MEDICAID |