Provider Demographics
NPI:1043215049
Name:GARDNER, LYNNELL P (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNNELL
Middle Name:P
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6761 E TANQUE VERDE RD
Mailing Address - Street 2:STE 6
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-5323
Mailing Address - Country:US
Mailing Address - Phone:520-298-2313
Mailing Address - Fax:520-298-1554
Practice Address - Street 1:6761 E TANQUE VERDE RD
Practice Address - Street 2:STE 6
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-5323
Practice Address - Country:US
Practice Address - Phone:520-298-2313
Practice Address - Fax:520-298-1554
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18444207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ283870Medicaid
D34675Medicare UPIN
AZMD18444Medicare ID - Type Unspecified