Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 252 | NM |
Y | 222Z00000X | Podiatrist | 252 | NM |
NPI | 1003980178 |
---|---|
Provider Name | Gay L Gustafson |
First Address | Albuquerque, NM 87110-4616 |
Second Address | Albuquerque, NM 87110-4616 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2006 |
Last Update Date | 10/07/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q4698 | (05) | NM |
U66743 | (02) |