Provider Demographics
NPI:1508954421
Name:GARDNER, JOHN WESLEY IV (RN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WESLEY
Last Name:GARDNER
Suffix:IV
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3441 CARSON RD
Mailing Address - Street 2:
Mailing Address - City:CAMINO
Mailing Address - State:CA
Mailing Address - Zip Code:95709
Mailing Address - Country:US
Mailing Address - Phone:530-647-9704
Mailing Address - Fax:530-644-8420
Practice Address - Street 1:1080 MARSHALL WAY
Practice Address - Street 2:MARSHALL HOSPITAL
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667
Practice Address - Country:US
Practice Address - Phone:530-622-1441
Practice Address - Fax:530-622-8655
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA468480163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant