Provider Demographics
NPI:1679041412
Name:GARDNER, NOLAN M (PT)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 5TH AVE APT 6L
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3996
Mailing Address - Country:US
Mailing Address - Phone:914-400-1500
Mailing Address - Fax:914-478-8781
Practice Address - Street 1:139 E 57TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2102
Practice Address - Country:US
Practice Address - Phone:212-753-4767
Practice Address - Fax:212-753-4076
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty