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General NPI Number Information
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NPI Number | 1174509103
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Entity Type | Individual
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Provider Name | JULIA A GUSTAFSON NP
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Gender | Female
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Dates
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Enumeration Date | 12/21/2005
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Last Update Date | 11/18/2016
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Provider Practice Location Address
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Address Line | 12811 COVEY CIR
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City | SONORA
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State | CA
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Zip | 95370-5935
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Country | US
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Telephone | 209-588-8840
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Fax | 209-588-0911
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Provider Business Mailing Address
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Address Line | 13989 STANTON CIR
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City | SONORA
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State | CA
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Zip | 95370-8641
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Country | US
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Telephone | 209-588-5584
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Fax | 209-588-0911
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | NP5485
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License Number State | CA
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