Provider Demographics
NPI:1679117451
Name:GARDNER, MARIO (APRN)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:917 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6651
Mailing Address - Country:US
Mailing Address - Phone:508-623-9798
Mailing Address - Fax:850-862-0605
Practice Address - Street 1:137 CRYSTAL BEACH DR STE 121
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-3573
Practice Address - Country:US
Practice Address - Phone:850-807-4388
Practice Address - Fax:850-862-0605
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11006004363L00000X, 2083P0011X
FLRN9265919163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105938800Medicaid