Provider Demographics
NPI:1477868925
Name:GARDNER, EDWARD CABELL
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CABELL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 FARM VIEW RD
Mailing Address - Street 2:
Mailing Address - City:GLADE HILL
Mailing Address - State:VA
Mailing Address - Zip Code:24092-1799
Mailing Address - Country:US
Mailing Address - Phone:540-493-5683
Mailing Address - Fax:540-483-4453
Practice Address - Street 1:1305 FARM VIEW RD
Practice Address - Street 2:
Practice Address - City:GLADE HILL
Practice Address - State:VA
Practice Address - Zip Code:24092-1799
Practice Address - Country:US
Practice Address - Phone:540-493-5683
Practice Address - Fax:540-483-4453
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-09
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA171W00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor