Provider Demographics
NPI:1467980177
Name:GARDNER, KIRSTEN (DO)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7847 FOREST EDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-5844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 RIVERSIDE CIR STE 300
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4962
Practice Address - Country:US
Practice Address - Phone:540-581-0238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
VA0116033802207QA0505X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program