Provider Demographics
NPI:1124415229
Name:GARDNER, DEAN
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6564
Mailing Address - Fax:315-298-7488
Practice Address - Street 1:61 DELANO ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-1400
Practice Address - Country:US
Practice Address - Phone:315-298-6564
Practice Address - Fax:315-298-7488
Is Sole Proprietor?:No
Enumeration Date:2015-04-16
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023498225100000X
NYF344984363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist