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General NPI Number Information
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NPI Number | 1215636121
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Entity Type | Individual
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Provider Name | KATELYN GUSTAFSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/28/2023
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Last Update Date | 11/03/2025
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Provider Practice Location Address
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Address Line | 621 S NEW BALLAS RD STE 560A
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8261
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Country | US
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Telephone | 314-251-6440
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Fax | 314-251-4456
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Provider Business Mailing Address
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Address Line | 621 S NEW BALLAS RD STE 560A
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City | SAINT LOUIS
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State | MO
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Zip | 63141-8261
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Country | US
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Telephone | 314-251-6440
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Fax | 314-251-4456
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2025044201
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA.0007815
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License Number State | CO
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