Provider Demographics
NPI:1386867166
Name:GARD, JOHN PATRICK (OTR, CHT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PATRICK
Last Name:GARD
Suffix:
Gender:M
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 THATCHER AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1036
Mailing Address - Country:US
Mailing Address - Phone:719-565-2002
Mailing Address - Fax:
Practice Address - Street 1:4301 THATCHER AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1036
Practice Address - Country:US
Practice Address - Phone:719-565-2002
Practice Address - Fax:719-564-7776
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO984839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO485948Medicare ID - Type Unspecified