Gustafson, Shane Michael

Gustafson, Shane Michael is an individual health care provider with primary practice located at 8100 Northland Dr , Bloomington MN 55431-4800. He recently has only one registered license in Allopathic & Osteopathic Physicians / Sports Medicine, which is considered as his primary health care specialty. Gustafson, Shane Michael can be contacted via phone (952) 831-8742.

Contact Information

Primary practice address
8100 Northland Dr Bloomington MN 55431-4800
Phone: (952) 831-8742
Fax:
Website:
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Health care specialties

SpecialtyCodeLicense #State
Allopathic & Osteopathic Physicians / Sports Medicine 207QS0010X 34-008344 Ohio
Allopathic & Osteopathic Physicians / Sports Medicine 207QS0010X 50252 Minnesota

Profile Details

NPI number 1922017623
LBN Legal business name Gustafson, Shane Michael
Credentials Doctor of Osteopathy (DO)
Entity Individual
Sole proprietor 1 No
Enumeration date Aug 5th, 2006
Last updated Jun 17th, 2021 - about 4 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1922017623 NPPES
Minnesota Other 080016479 MEDICARE
Minnesota MEDICAID 935408000 MEDICARE

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