Healthcare Provider Details

I. General information

NPI: 1891101929
Provider Name (Legal Business Name): KELLIE A GUSTAS P.A-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920A BRIDGE RD STE 202
SUFFOLK VA
23435-1117
US

IV. Provider business mailing address

3920A BRIDGE RD STE 202
SUFFOLK VA
23435-1117
US

V. Phone/Fax

Practice location:
  • Phone: 757-983-0330
  • Fax: 757-431-7788
Mailing address:
  • Phone: 757-983-0330
  • Fax: 757-431-7788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056903
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110011923
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: