Provider Demographics
NPI:1366429318
Name:GONNERMAN, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:GONNERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:IA
Mailing Address - Zip Code:50548-1728
Mailing Address - Country:US
Mailing Address - Phone:515-332-2755
Mailing Address - Fax:
Practice Address - Street 1:405 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:IA
Practice Address - Zip Code:50548-1728
Practice Address - Country:US
Practice Address - Phone:515-332-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0132266Medicaid
IA13226OtherBCBS
IA0132266Medicaid