Provider Demographics
NPI:1669641973
Name:GARDNER, JASON L (MPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 DESERT LILY CT SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1562
Mailing Address - Country:US
Mailing Address - Phone:505-385-5080
Mailing Address - Fax:
Practice Address - Street 1:W 4824 MCMAHON BLVD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114
Practice Address - Country:US
Practice Address - Phone:505-897-3537
Practice Address - Fax:505-897-3726
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist