Provider Demographics
NPI:1366453185
Name:GARDNER, SPENCER R (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SPENCER
Middle Name:R
Last Name:GARDNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 FIVE CENT RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-8412
Mailing Address - Country:US
Mailing Address - Phone:252-343-6677
Mailing Address - Fax:
Practice Address - Street 1:1336 FIVE CENT RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-8412
Practice Address - Country:US
Practice Address - Phone:252-343-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC051808367500000X
NC2449367500000X
NC149935163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051543Medicaid
NC430057893Medicare PIN
NC8051543Medicaid