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Individual
TY C. GULSTROM
Active
Individual
TY C. GULSTROM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA- C
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
PA10004348
WA
363A00000X
Physician Assistant
Primary
PA10004348
WA
363AM0700X
Medical Physician Assistant
PA10004348
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0216864
LIWA
WA
01
—
3479GU
BSWA
WA
01
—
605960012
USDLAB
—
05
—
8386484
—
WA
Enumeration date
06/17/2006
Last updated
02/18/2015
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