Provider Demographics
NPI:1174876403
Name:GARDNER, CARRIE A (PA)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
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 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4150
Practice Address - Street 1:3000 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:OH
Practice Address - Zip Code:45103-1921
Practice Address - Country:US
Practice Address - Phone:513-732-8200
Practice Address - Fax:937-619-4150
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH50.003637363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant