# TY C. GULSTROM

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1558306373
- **Gender:** Man
- **Credential:** PA- C

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207P00000X | Emergency Medicine Physician | PA10004348 | WA | — |
| 363A00000X | Physician Assistant | PA10004348 | WA | Yes |
| 363AM0700X | Medical Physician Assistant | PA10004348 | WA | — |

## Other

- **Enumeration date:** 06/17/2006
- **Last updated:** 02/18/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 0216864 | LIWA | WA |
| 01 | — | 3479GU | BSWA | WA |
| 01 | — | 605960012 | USDLAB | — |
| 05 | — | 8386484 | — | WA |