Provider Demographics
NPI:1710932363
Name:GARDNER, TRUDIE (PA-C)
Entity Type:Individual
Prefix:
First Name:TRUDIE
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N ROAD ST
Mailing Address - Street 2:BLDG.9
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3365
Mailing Address - Country:US
Mailing Address - Phone:252-338-9451
Mailing Address - Fax:252-338-9170
Practice Address - Street 1:4923 S CROATAN HWY
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9709
Practice Address - Country:US
Practice Address - Phone:252-261-8040
Practice Address - Fax:252-441-7041
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC100094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare ID - Type Unspecified