Provider Demographics
NPI:1003104993
Name:GARDNER, GARY JOHN (NP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:JOHN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-3952
Mailing Address - Country:US
Mailing Address - Phone:618-363-9545
Mailing Address - Fax:
Practice Address - Street 1:4251 FOREST PARK AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2810
Practice Address - Country:US
Practice Address - Phone:618-363-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-13
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005922363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health