Healthcare Provider Details

I. General information

NPI: 1821213612
Provider Name (Legal Business Name): THOMAS C GUSTAFSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 NW MARKET ST
SEATTLE WA
98107-5225
US

IV. Provider business mailing address

1717 NW MARKET ST
SEATTLE WA
98107-5225
US

V. Phone/Fax

Practice location:
  • Phone: 206-782-0500
  • Fax: 206-782-0502
Mailing address:
  • Phone: 206-782-0500
  • Fax: 206-782-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberOP00001187
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP30007148
License Number StateWA

VIII. Authorized Official

Name: DR. THOMAS CARL GUSTAFSON
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 206-782-0500