Provider Demographics
NPI:1053083865
Name:GARDNER, NATHAN (PMHNP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S RED RIVER ST
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-3709
Mailing Address - Country:US
Mailing Address - Phone:940-228-6510
Mailing Address - Fax:
Practice Address - Street 1:1407 W STASSNEY LN
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-2947
Practice Address - Country:US
Practice Address - Phone:512-440-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1055941363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty