MEDICARE: CHRISTOPHER G GASTELUM SR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZC0007X	Surgical Assistant	16-154	WI

General Provider Information

NPI Number	:	1083075980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER G GASTELUM SR.

Provider Business Mailing Address
First Line	:	1748 VICTOR HUGO LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-8231
Country	:	US
Telephone Number	:	702-793-8414
Fax Number	:

Provider Business Practice Location Address
First Line	:	1748 VICTOR HUGO LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-8231
Country	:	US
Telephone Number	:	702-793-8414
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2016
Last Update Date	:	03/19/2016

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