Provider Demographics
NPI:1629315239
Name:GARDNER, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PINTCHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5700 DARROW RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5026
Mailing Address - Country:US
Mailing Address - Phone:330-656-9304
Mailing Address - Fax:330-656-5901
Practice Address - Street 1:13207 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7032
Practice Address - Country:US
Practice Address - Phone:330-656-9304
Practice Address - Fax:330-656-5901
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant