Provider Demographics
NPI:1306571302
Name:GUSTAVSON, ANDREW KIRBY (PA-C)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:KIRBY
Last Name:GUSTAVSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3614 PROVIDENCE RD S STE 200
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6310
Practice Address - Country:US
Practice Address - Phone:704-384-8640
Practice Address - Fax:704-384-8650
Is Sole Proprietor?:No
Enumeration Date:2022-07-22
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-12435363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant