Provider Demographics
NPI:1609839687
Name:GARDNER, CHRISTINA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-2080
Mailing Address - Country:US
Mailing Address - Phone:804-435-3508
Mailing Address - Fax:
Practice Address - Street 1:101 ELM AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24013-2222
Practice Address - Country:US
Practice Address - Phone:540-985-8000
Practice Address - Fax:540-981-9550
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002184363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010211590Medicaid
P00266768OtherRR MEDICARE
VA010211581Medicaid
VA010212502Medicaid
P00266768OtherRR MEDICARE
VA010211590Medicaid
P00266768Medicare PIN