Provider Demographics
NPI:1598493025
Name:GARDNER, WILIAM SAMUEL (ATC)
Entity Type:Individual
Prefix:
First Name:WILIAM
Middle Name:SAMUEL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5417 BOXWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MS
Mailing Address - Zip Code:39342-9018
Mailing Address - Country:US
Mailing Address - Phone:601-917-6781
Mailing Address - Fax:
Practice Address - Street 1:5417 BOXWOOD LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MS
Practice Address - Zip Code:39342-9018
Practice Address - Country:US
Practice Address - Phone:601-917-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT04212255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer