Basic Information
| Provider Information | |||||||||
| NPI: | 1659551612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUSTIN | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S COOLIDGE ST | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097939715 | ||||||||
| FaxNumber: | 5097643244 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E WHEELER RD | ||||||||
| Address2: | |||||||||
| City: | MOSES LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988371820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097655606 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2007 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 228596 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP117632 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | N-31328 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 0024168059 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 745525 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 101051 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 74249 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | AP30007545 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1056739 | 05 | WA | MEDICAID |