Provider Demographics
NPI:1629174776
Name:GARDINER, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GARDINER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4103 DECOURSEY AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41015-1811
Mailing Address - Country:US
Mailing Address - Phone:859-261-6383
Mailing Address - Fax:
Practice Address - Street 1:55 PROGRESS PL
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-1715
Practice Address - Country:US
Practice Address - Phone:513-346-5000
Practice Address - Fax:513-671-2003
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0099363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2043868Medicaid
OH2043868Medicaid
OHS65765Medicare UPIN