Provider Demographics
NPI:1417468547
Name:GARDNER, ROSA LOUISE BREY (PA)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:LOUISE BREY
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:
Other - Last Name:BREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 IDLEWILD DR UNIT 428
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1075
Mailing Address - Country:US
Mailing Address - Phone:406-599-1056
Mailing Address - Fax:
Practice Address - Street 1:2333 N 6TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2001
Practice Address - Country:US
Practice Address - Phone:970-298-1792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant