Provider Demographics
NPI:1326005653
Name:GARDNER, CARSON T (MD)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:T
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26246 CRANE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE EARTH
Mailing Address - State:MN
Mailing Address - Zip Code:56591-9998
Mailing Address - Country:US
Mailing Address - Phone:218-983-3286
Mailing Address - Fax:
Practice Address - Street 1:26246 CRANE RD
Practice Address - Street 2:
Practice Address - City:WHITE EARTH
Practice Address - State:MN
Practice Address - Zip Code:56591-9998
Practice Address - Country:US
Practice Address - Phone:218-983-3286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0107998OtherMEDICA
MN160003600Medicaid
585241029522OtherPREFERRED ONE
43P02GAOtherBCBS
585241029522OtherPREFERRED ONE
D75435Medicare UPIN