Provider Demographics
NPI:1134113020
Name:GARDAM, CLAIRE ELAINE (NP)
Entity Type:Individual
Prefix:MRS
First Name:CLAIRE
Middle Name:ELAINE
Last Name:GARDAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CLAIRE
Other - Middle Name:ELAINE
Other - Last Name:AHLQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:19 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1338
Mailing Address - Country:US
Mailing Address - Phone:315-386-3482
Mailing Address - Fax:
Practice Address - Street 1:16 3RD ST
Practice Address - Street 2:STE C
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1305
Practice Address - Country:US
Practice Address - Phone:518-483-1015
Practice Address - Fax:518-483-0430
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3600271207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology