Provider Demographics
NPI:1811142524
Name:25/34 PLASTIC SURGERY ASSOCIATES, PC
Entity type:Organization
Organization Name:25/34 PLASTIC SURGERY ASSOCIATES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:GONYON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:970-624-7979
Mailing Address - Street 1:4450 UNION ST.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534
Mailing Address - Country:US
Mailing Address - Phone:970-624-7979
Mailing Address - Fax:970-624-7980
Practice Address - Street 1:4450 UNION ST.
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSTOWN
Practice Address - State:CO
Practice Address - Zip Code:80534-0001
Practice Address - Country:US
Practice Address - Phone:970-624-7979
Practice Address - Fax:970-624-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43327174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12683027Medicaid
CO12683027Medicaid