Provider Demographics
NPI:1689701260
Name:GARDINER, SHANNON L (PA)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:L
Last Name:GARDINER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-985-1423
Mailing Address - Fax:208-955-6501
Practice Address - Street 1:875 S VANGUARD WAY STE 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8542
Practice Address - Country:US
Practice Address - Phone:208-809-2895
Practice Address - Fax:208-809-2896
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA403363A00000X
IDPA-403363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806483300Medicaid
IDP80381Medicare UPIN
ID1667729Medicare PIN