Provider Demographics
NPI:1134127590
Name:GARDNER, WAYNE M (PA)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 BRANTLEY PLACE CIR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-6854
Mailing Address - Country:US
Mailing Address - Phone:407-733-5464
Mailing Address - Fax:
Practice Address - Street 1:3844 BRANTLEY PLACE CIR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-6854
Practice Address - Country:US
Practice Address - Phone:407-733-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3289363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290329600Medicaid
FLE0519Medicare ID - Type UnspecifiedINDIV. MEDICARE NUMBER
FL290329600Medicaid
FL00364Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER