Individual
SHANE MICHAEL GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
8100 NORTHLAND DR, BLOOMINGTON, MN 55431-4800
(952) 831-8742
Mailing address
8170 33RD AVE S # MS 21110Q, BLOOMINGTON, MN 55425-4516
Taxonomy
Speciality
Code
Description
License number
State
207QS0010X
Sports Medicine (Family Medicine) Physician
34-008344
OH
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
50252
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
080016479
MEDICARE
MN
05
—
935408000
—
MN
Enumeration date
08/05/2006
Last updated
06/17/2021
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