Healthcare Provider Details

I. General information

NPI: 1902357171
Provider Name (Legal Business Name): TROY GUSTAVESON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 01/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 N LA CHOLLA BLVD
TUCSON AZ
85741-3535
US

IV. Provider business mailing address

5910 N LA CHOLLA BLVD
TUCSON AZ
85741-3535
US

V. Phone/Fax

Practice location:
  • Phone: 520-297-0404
  • Fax: 520-297-0436
Mailing address:
  • Phone: 520-297-0404
  • Fax: 520-297-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6477
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: