Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208000000X | Pediatrician | MD00048546 | WA |
NPI | 1003926387 |
---|---|
Provider Name | Eric Albert Gustafson |
First Address | Bellevue, WA 98007-7666 |
Second Address | Bellevue, WA 98004-1463 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 26/09/2011 |