Provider Demographics
NPI:1700043692
Name:ANTONSON, GWYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:GWYNN
Middle Name:
Last Name:ANTONSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 JERRY MURPHY RD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1045
Mailing Address - Country:US
Mailing Address - Phone:719-546-3600
Mailing Address - Fax:719-546-0931
Practice Address - Street 1:4020 JERRY MURPHY RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1045
Practice Address - Country:US
Practice Address - Phone:719-546-3600
Practice Address - Fax:719-546-0931
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0050578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65425871Medicaid