Provider Demographics
NPI:1093589129
Name:GUSTAFSON, HANNA (PA-C)
Entity type:Individual
Prefix:
First Name:HANNA
Middle Name:
Last Name:GUSTAFSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 THORNTON CT
Mailing Address - Street 2:
Mailing Address - City:FORT JOHNSON
Mailing Address - State:LA
Mailing Address - Zip Code:71459-3109
Mailing Address - Country:US
Mailing Address - Phone:832-622-6110
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT JOHNSON
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant