Provider Demographics
NPI:1245573328
Name:GARDNER, ABBY MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:ABBY
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:ABBY
Other - Middle Name:MARIE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1300 E MULLAN AVE STE 1800
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4855
Mailing Address - Country:US
Mailing Address - Phone:208-625-3700
Mailing Address - Fax:208-625-3701
Practice Address - Street 1:1300 E MULLAN AVE STE 1800
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6052
Practice Address - Country:US
Practice Address - Phone:208-625-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362073401Medicaid
TX8FX748OtherBCBS
TXP01802221OtherRAILROAD MEDICARE