Provider Demographics
NPI:1134316581
Name:GARDNER, ROSEMARY L (PA)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:713 TROY SCHENECTADY RD STE 215
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2490
Practice Address - Country:US
Practice Address - Phone:518-713-5347
Practice Address - Fax:518-713-5359
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY23012078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02987364Medicaid