Provider Demographics
NPI:1629089065
Name:GARDNER, BEVERLY JOAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:JOAN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 S WEBB AVE
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-8452
Mailing Address - Country:US
Mailing Address - Phone:931-484-5379
Mailing Address - Fax:931-484-5946
Practice Address - Street 1:131 S WEBB AVE
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-8452
Practice Address - Country:US
Practice Address - Phone:931-484-5379
Practice Address - Fax:931-484-5946
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA632363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00239251OtherRAILROAD MEDICARE
S46399Medicare UPIN
TN3667098Medicare ID - Type Unspecified