Provider Demographics
NPI:1376908830
Name:GARDNER, ARIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:ARIEL
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4208 MURDOCKSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST END
Mailing Address - State:NC
Mailing Address - Zip Code:27376-8871
Mailing Address - Country:US
Mailing Address - Phone:910-235-5900
Mailing Address - Fax:910-235-3447
Practice Address - Street 1:4208 MURDOCKSVILLE RD
Practice Address - Street 2:
Practice Address - City:WEST END
Practice Address - State:NC
Practice Address - Zip Code:27376-8871
Practice Address - Country:US
Practice Address - Phone:910-235-5900
Practice Address - Fax:910-235-3447
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-11189363A00000X
CA56812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ023242Medicaid