Provider Demographics
NPI:1710088141
Name:GARDNER, LANCE LEE (PT)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:LEE
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 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 RISING SUN TOWN CTR
Practice Address - Street 2:
Practice Address - City:RISING SUN
Practice Address - State:MD
Practice Address - Zip Code:21911-1902
Practice Address - Country:US
Practice Address - Phone:410-658-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0151772251X0800X
MD22795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3117934OtherUS HEALTH CARE
PAGA1446210OtherBLUE SHIELD
PA2129596000OtherKEYSTONE
PA11227669OtherCAQH
PA11227669OtherCAQH