Individual
LESLIE GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
17550 PROVOST ST STE 201, LAKE OSWEGO, OR 97034-5199
(503) 872-2440
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
(503) 215-6494
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA170542
OR
Other
Enumeration date
12/04/2014
Last updated
02/12/2021
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