SHANE MICHAEL GUSTAFSON (NPI# 1922017623) is a health care provider registered in Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES).
| Nation Provider ID (NPI) | 1922017623 |
| Entity Type | Individual |
| Full Name | SHANE MICHAEL GUSTAFSON |
| Credential | DO |
| Practice Address |
8100 Northland Dr Bloomington MN 55431-4800 |
| Practice Telephone | 9528318742 |
| Enumeration Date | 2006-08-05 |
| Last Update Date | 2018-05-30 |
| Gender Code | M |
| Is Sole Proprietor | N |
| Primary | Taxonomy Code | Classification | License Number | License State | Taxonomy Group |
|---|---|---|---|---|---|
| Y | 207QS0010X |
Family Medicine Specialization: Sports Medicine |
50252 | MN | Allopathic & Osteopathic Physicians |
| N | 207QS0010X |
Family Medicine Specialization: Sports Medicine |
34-008344 | OH | Allopathic & Osteopathic Physicians |
| State | Issuer | Identifier | Type Code |
|---|---|---|---|
| MN | MEDICARE | 080016479 | 01 |
| MN | 935408000 | 05 |
| Address | Telephone Number | Fax Number |
|---|---|---|
| 1901 Connecticut Ave S, Sartell, MN 56377 | 3202292118 | 3202598044 |
| Street Address |
8100 NORTHLAND DR |
| City | BLOOMINGTON |
| State | MN |
| Zip Code | 55431-4800 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1780150946 | Dillon Bruxvoort | Specialist/Technologist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2018-10-15 |
| 1619452026 | Julia Mcbrien | Occupational Therapist | 8100 Northland Dr, Bloomington, MN 55431 | 2018-10-02 |
| 1821508433 | Adam Jansen | Occupational Therapist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2017-10-09 |
| 1184148017 | Andrew Jacob Olson | Neuromusculoskeletal Medicine, Sports Medicine | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2017-08-02 |
| 1831629849 | Brianna Marie Bosma | Physical Therapist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2017-06-13 |
| 1740720283 | Joshua Michael Brodersen | Specialist/Technologist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2017-03-02 |
| 1629512124 | Lisa Marie Boberg | Specialist/Technologist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2016-12-19 |
| 1518411776 | Amy Haynes | Physical Therapist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2016-08-04 |
| 1659731222 | Connor Roach | Occupational Therapist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2016-02-25 |
| 1659744043 | Aimee Custer | Clinical Neuropsychologist | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2015-11-05 |
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| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1578162509 | Mckenzie Mcadaragh | Nurse Practitioner | 10924 Girard Curve, Bloomington, MN 55431 | 2020-10-21 |
| 1760042253 | Adams Health Care Services, LLC | Registered Nurse | 10036 Washburn Ave S, Bloomington, MN 55431 | 2019-06-17 |
| 1851864755 | Hope Autism Center | Day Training, Developmentally Disabled Services | 9333 Penn Ave S, Bloomington, MN 55431 | 2019-01-03 |
| 1275006215 | Cameron Lee Small | Counselor | 9156 Vincent Ave S, Bloomington, MN 55431 | 2019-01-02 |
| 1497240469 | Mikayla Slegh | Behavior Technician | 8200 Humboldt Ave S Suite 100, Bloomington, MN 55431 | 2018-06-22 |
| 1073061552 | David Wells | Nurse Practitioner | 8100 Northland Dr., Bloomington, MN 55431 | 2016-09-14 |
| 1780033076 | Yasin Jama | Contractor | 9810 Drew Avenue South, Apartment 106, Bloomington, MN 55431 | 2016-06-07 |
| 1972961001 | Kadar Hadis | Social Worker | 8200 Humboldt Ave S Ste 217, Bloomington, MN 55431 | 2016-02-03 |
| 1063878908 | Amazing Transportation Services, LLC | Non-emergency Medical Transport (VAN) | 9031 Penn Ave South Suite 100, Bloomington, MN 55431 | 2016-01-07 |
| 1093170136 | Kelsey Margaret Perreault | Chiropractor | 8120 Penn Ave. S., Suite 525, Bloomington, MN 55431 | 2015-12-16 |
| Find all providers in zip 55431 | ||||
| Taxonomy Code | 207QS0010X |
| Grouping | Allopathic & Osteopathic Physicians |
| Classification | Family Medicine |
| Specialization | Sports Medicine |
| A family medicine physician that is trained to be responsible for continuous care in the field of sports medicine, not only for the enhancement of health and fitness, but also for the prevention of injury and illness. A sports medicine physician must have knowledge and experience in the promotion of wellness and the prevention of injury. Knowledge about special areas of medicine such as exercise physiology, biomechanics, nutrition, psychology, physical rehabilitation, epidemiology, physical evaluation, injuries (treatment and prevention and referral practice) and the role of exercise in promoting a healthy lifestyle are essential to the practice of sports medicine. The sports medicine physician requires special education to provide the knowledge to improve the health care of the individual engaged in physical exercise (sports) whether as an individual or in team participation. |
| Notes: Source: American Board of Medical Specialties, 2007. www.abms.org [7/1/2007: added definition, added source; 7/1/2011: modified source] - Additional Resources: American Board of Family Medicine, 2007. http://www.theabfm.org/. American Osteopathic Board of Family Medicine, 2007. http://www.osteopathic.org/certification - Board certification for Medical Doctors (MDs) is provided by the American Board of Family Medicine. Board certification for Doctors of Osteopathy (DOs) is provided by the American Osteopathic Board of Family Medicine. |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1649598707 | Rajih Y Haddawi | Family Medicine | 2631 S Atlee St, Bloomington, IN 47401-4536 | 2010-05-12 |
| 1144617366 | Mckayla Schmitt | Family Medicine | 8100 Northland Dr, Bloomington, MN 55431-4800 | 2015-04-26 |
| 1336538917 | The Trustees of Indiana University | Family Medicine | 1001 E 17th St, Assembly Hall, Bloomington, IN 47408-1590 | 2015-01-20 |
| 1659684462 | Premier Healthcare, LLC | Family Medicine | 2605 E Creeks Edge Dr, Bloomington, IN 47401-8368 | 2010-07-21 |
| 1184855272 | Ima East Primary Care | Family Medicine | 2605 E Creeks Edge Dr, Bloomington, IN 47401-8368 | 2009-08-06 |
| 1285890764 | Heather J Dukes Rosales | Family Medicine | 2605 E Creeks Edge Dr, Bloomington, IN 47401-8368 | 2008-08-04 |
| 1235396045 | Ryan Niehaus | Family Medicine | 995 S Clarizz Blvd, Bloomington, IN 47401-5588 | 2008-05-20 |
| 1649237504 | Wendell W Becton | Family Medicine | 1111 Trinity Lane, Suite 111, Bloomington, IL 61704-3738 | 2006-04-26 |
| NPI | Name | Taxonomy | Address | Enumeration |
|---|---|---|---|---|
| 1316239361 | David Ian Smith | Family Medicine | 516 15th Ave Se Ste 190e, Minneapolis, MN 55455-0130 | 2011-05-10 |
| 1306163571 | Maria Christine Ryan | Family Medicine | 15450 Highway 7 Ste 125, Minnetonka, MN 55345-3522 | 2010-04-28 |
| 1659437267 | Peter Swann | Family Medicine | 1400 Corporate Center Curv Ste 200, Eagan, MN 55121-1372 | 2006-12-28 |
| 1275557886 | Odom Sports Medicine, P.a. | Family Medicine | 10653 Wayzata Blvd Ste 200, Minnetonka, MN 55305-1543 | 2006-07-27 |
| 1790739092 | Ronald Wayne Hanson Jr. | Family Medicine | 6636 Cedar Ave S Ste 170, Richfield, MN 55423-2710 | 2006-05-20 |
| 1669423950 | Suzanne S Hecht | Family Medicine | 2512 South 7th Street, First Floor, R102, University Orthopeadics, Minneapolis, MN 55454-1404 | 2006-05-12 |
| 1295231702 | Rachel Kwiatkowski | Family Medicine | 550 Osborne Rd Ne, Fridley, MN 55432-2718 | 2018-04-03 |
| 1255793261 | Arie Degrio | Family Medicine | 1601 Golf Course Rd, Grand Rapids, MN 55744-8648 | 2016-03-28 |
| 1437525292 | Orthocure LLC | Family Medicine | 6636 Cedar Ave S Ste 170, Richfield, MN 55423-2710 | 2015-08-17 |
| 1871974022 | Mark Cipriani Jr. | Family Medicine | 200 1st St Sw, Rochester, MN 55905-0001 | 2015-06-13 |
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| City | BLOOMINGTON |
| Zip Code | 55431 |
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| Data Provider | Centers for Medicare & Medicaid Services (CMS), National Plan and Provider Enumeration System (NPPES) |
| Jurisdiction | Medicare & Medicaid |
This dataset includes 5.44 million covered health care providers and all health plans and health care clearinghouses, registered with CMA NPPES. Each provider is registered with National Provider Identifier (NPI), full name, status, address, taxonomy, other identifiers, etc.