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NPI Code Detail

MEDICARE: LESLIE GUSTAFSON PA-C

MEDICARE: LESLIE GUSTAFSON PA-C
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
1363A00000XPhysician AssistantPA170542OR

General Provider Information

NPI Number : 1922405059
Entity Type Code : Individual
Provider Name (Legal Business Name) : LESLIE GUSTAFSON PA-C
Provider Business Mailing Address
First Line : PO BOX 3158
Second Line :
City : PORTLAND
State : OR
Zip : 97208-3158
Country : US
Telephone Number : 503-215-6494
Fax Number :
Provider Business Practice Location Address
First Line : 17550 PROVOST ST STE 201
Second Line :
City : LAKE OSWEGO
State : OR
Zip : 97034-5199
Country : US
Telephone Number : 503-872-2440
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/04/2014
Last Update Date : 02/12/2021

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Directions to “ LESLIE GUSTAFSON PA-C” Practice Location

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