Provider Demographics
NPI:1679907802
Name:GARDNER, JUANITA ANN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:JUANITA
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 RACE ST
Mailing Address - Street 2:MAIL STOP 503
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-1119
Mailing Address - Country:US
Mailing Address - Phone:215-762-3083
Mailing Address - Fax:215-762-1164
Practice Address - Street 1:1505 RACE ST
Practice Address - Street 2:MAIL STOP 503
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1119
Practice Address - Country:US
Practice Address - Phone:215-762-3083
Practice Address - Fax:215-762-1164
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001936L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant