MEDICARE: MRS. MEGHAN PATRICIA GUSTAFSON RN, CPNP

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	363LP0200X	Pediatric Nurse Practitioner	RN 131621	MO
2	363LP0200X	Pediatric Nurse Practitioner	1096404	TX

General Provider Information

NPI Number	:	1235252982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MEGHAN PATRICIA GUSTAFSON RN, CPNP

Provider Business Mailing Address
First Line	:	4823 ISLEWORTH DR
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75038-4500
Country	:	US
Telephone Number	:	636-544-0639
Fax Number	:

Provider Business Practice Location Address
First Line	:	5323 HARRY HINES BLVD STOP 7200
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75390-1002
Country	:	US
Telephone Number	:	214-648-3111
Fax Number	:

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

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	08/15/2023

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