MEDICARE: MRS. EVA MARIE GUSTAFSON PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	4231-024	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730352758
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EVA MARIE GUSTAFSON PT

Provider Business Mailing Address
First Line	:	7830 STATE HIGHWAY 13
Second Line	:
City	:	PORT WING
State	:	WI
Zip	:	54865-4721
Country	:	US
Telephone Number	:	715-774-3195
Fax Number	:

Provider Business Practice Location Address
First Line	:	7830 STATE HIGHWAY 13
Second Line	:
City	:	PORT WING
State	:	WI
Zip	:	54865-4721
Country	:	US
Telephone Number	:	715-774-3195
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2008
Last Update Date	:	04/10/2008

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