MEDICARE: SARAH LYNN GUSTAFSON P.T.

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	225100000X	Physical Therapist	PT00009125	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2034653	OTHER		INTERNAL ID-MOTOR VEHICLE ID

General Provider Information

NPI Number	:	1821173626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH LYNN GUSTAFSON P.T.

Provider Business Mailing Address
First Line	:	PO BOX 50095
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98145-5095
Country	:	US
Telephone Number	:	206-543-6420
Fax Number	:

Provider Business Practice Location Address
First Line	:	3850 MONTLAKE BLVD NE RM 148 B
Second Line	:	ARENA/HEC EDMUNDSON PAVILLION
City	:	SEATTLE
State	:	WA
Zip	:	98195-0001
Country	:	US
Telephone Number	:	206-543-1552
Fax Number	:

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

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	07/08/2007

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