Provider Demographics
NPI:1689945693
Name:GARDNER, SETH D (PA)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-1686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1321
Practice Address - Fax:863-284-1730
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-23
Last Update Date:2017-08-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9109363363AS0400X, 363AS0400X
ARP-T1339363AM0700X
MO2012001195363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical