Provider Demographics
NPI:1114909439
Name:GARDNER, PAUL MATTHEW (MPT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MATTHEW
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 8TH AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PLATTSMOUTH
Mailing Address - State:NE
Mailing Address - Zip Code:68048-2367
Mailing Address - Country:US
Mailing Address - Phone:402-296-3433
Mailing Address - Fax:402-296-3531
Practice Address - Street 1:2380 8TH AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:PLATTSMOUTH
Practice Address - State:NE
Practice Address - Zip Code:68048-2367
Practice Address - Country:US
Practice Address - Phone:402-296-3433
Practice Address - Fax:402-296-3531
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1922225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE08797OtherBLUE CROSS BLUE SHIELD
IA0581362Medicaid
NEP17305Medicare UPIN
IA0581362Medicaid