Provider Demographics
NPI:1417393927
Name:GUSTAFSON, SUSAN E (PA-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:E
Other - Last Name:BENTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:21 PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6247
Mailing Address - Country:US
Mailing Address - Phone:716-664-1909
Mailing Address - Fax:716-664-2214
Practice Address - Street 1:21 PORTER AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6247
Practice Address - Country:US
Practice Address - Phone:716-664-1909
Practice Address - Fax:716-664-2214
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060649363A00000X, 363AM0700X
NY016685363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical