Provider Demographics
NPI:1932252699
Name:CLINICAL NEUROSCIENCE ASSOCIATES, INC.
Entity type:Organization
Organization Name:CLINICAL NEUROSCIENCE ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-434-2743
Mailing Address - Street 1:300 S 8TH ST
Mailing Address - Street 2:SUITE 380W
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-2400
Mailing Address - Country:US
Mailing Address - Phone:270-753-8656
Mailing Address - Fax:270-767-3630
Practice Address - Street 1:1501 S WALDRON RD STE 202
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2598
Practice Address - Country:US
Practice Address - Phone:479-434-2743
Practice Address - Fax:844-454-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7890482800Medicaid