Healthcare Provider Details

I. General information

NPI: 1811142524
Provider Name (Legal Business Name): 25/34 PLASTIC SURGERY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 UNION ST. SUITE 100
JOHNSTOWN CO
80534-0001
US

IV. Provider business mailing address

4450 UNION ST. SUITE 100
JOHNSTOWN CO
80534
US

V. Phone/Fax

Practice location:
  • Phone: 970-624-7979
  • Fax: 970-624-7980
Mailing address:
  • Phone: 970-624-7979
  • Fax: 970-624-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number43327
License Number StateCO

VIII. Authorized Official

Name: DR. DENIS L GONYON JR.
Title or Position: OWNER
Credential: MD
Phone: 970-624-7979