Healthcare Provider Details

I. General information

NPI: 1679913560
Provider Name (Legal Business Name): ANDREW W GISLESON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 04/19/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

978 EUCLID AVE
CARBONDALE CO
81623-1820
US

IV. Provider business mailing address

978 EUCLID AVE
CARBONDALE CO
81623-1820
US

V. Phone/Fax

Practice location:
  • Phone: 970-963-3350
  • Fax: 970-963-2958
Mailing address:
  • Phone: 970-963-3350
  • Fax: 970-963-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number55479
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: