Provider Demographics
NPI:1326574807
Name:GARDNER, PRESTON
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1831
Mailing Address - Country:US
Mailing Address - Phone:503-238-5203
Mailing Address - Fax:503-238-5202
Practice Address - Street 1:2901 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1831
Practice Address - Country:US
Practice Address - Phone:503-238-5203
Practice Address - Fax:503-238-5202
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist