Provider Demographics
NPI:1639521180
Name:GARDNER, CHARLES N
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:N
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 MINE 10 RD
Mailing Address - Street 2:
Mailing Address - City:BECCARIA
Mailing Address - State:PA
Mailing Address - Zip Code:16616-9716
Mailing Address - Country:US
Mailing Address - Phone:814-577-7543
Mailing Address - Fax:
Practice Address - Street 1:1056 MINE 10 RD
Practice Address - Street 2:
Practice Address - City:BECCARIA
Practice Address - State:PA
Practice Address - Zip Code:16616-9716
Practice Address - Country:US
Practice Address - Phone:814-577-7543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE009265225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant