Provider Demographics
NPI:1093131690
Name:GARDNER, LISA ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 LAC DE VILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5647
Mailing Address - Country:US
Mailing Address - Phone:585-275-5321
Mailing Address - Fax:
Practice Address - Street 1:4901 LAC DE VILLE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5647
Practice Address - Country:US
Practice Address - Phone:585-275-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-07
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY17406363A00000X
NY017406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant