Healthcare Provider Details

I. General information

NPI: 1245976158
Provider Name (Legal Business Name): CHAD GUSTAFSON NRP, IDHS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 05/12/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 17TH ST NW
WASHINGTON DC
20500
US

IV. Provider business mailing address

1650 17TH ST NW
WASHINGTON DC
20500
US

V. Phone/Fax

Practice location:
  • Phone: 202-814-6607
  • Fax:
Mailing address:
  • Phone: 202-814-6607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: