Basic Information
| Provider Information | |||||||||
| NPI: | 1881810596 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONDA | ||||||||
| FirstName: | SHAUN | ||||||||
| MiddleName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076721046 | ||||||||
| FaxNumber: | 3076721149 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076721000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 6451 | KS | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 8052A | WY | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | 8052A | WY | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.