MEDICARE: EMMETT PLASTIC SURGERY, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	43763	CO

General Provider Information

NPI Number	:	1417265596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMETT PLASTIC SURGERY, PLLC

Provider Business Mailing Address
First Line	:	9362 TEDDY LN STE 103
Second Line	:
City	:	LONE TREE
State	:	CO
Zip	:	80124-2871
Country	:	US
Telephone Number	:	303-955-7545
Fax Number	:	303-955-7766

Provider Business Practice Location Address
First Line	:	9362 TEDDY LN STE 103
Second Line	:
City	:	LONE TREE
State	:	CO
Zip	:	80124-2871
Country	:	US
Telephone Number	:	303-955-7545
Fax Number	:	303-955-7766

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	JENNIFER EMMETT
Credential	:
Telephone Number	:	303-725-6618

Provider Enumeration Date	:	09/22/2010
Last Update Date	:	07/13/2021

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