Provider Demographics
NPI:1659733731
Name:GARDNER, TERA (CNP)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TERA
Other - Middle Name:
Other - Last Name:GERICKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:4005 HIGH RESORT BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-5906
Practice Address - Country:US
Practice Address - Phone:505-462-6000
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016009388363LF0000X
KS53-77233-122363LF0000X
NM54686363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96533544Medicaid