Provider Demographics
NPI:1710761812
Name:GARDNER, DYLAN SEAN
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:SEAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 PURA VIDA TRL
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-2692
Mailing Address - Country:US
Mailing Address - Phone:405-880-1234
Mailing Address - Fax:
Practice Address - Street 1:5606 PURA VIDA TRL
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-2692
Practice Address - Country:US
Practice Address - Phone:405-880-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant