Provider Demographics
NPI:1720192966
Name:GARDNER, SCOTT C (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 S HILLSDEN DR
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7167
Mailing Address - Country:US
Mailing Address - Phone:801-265-9128
Mailing Address - Fax:
Practice Address - Street 1:4488 HANALEI PLANTATION RD
Practice Address - Street 2:
Practice Address - City:PRINCEVILLE
Practice Address - State:HI
Practice Address - Zip Code:96722-5462
Practice Address - Country:US
Practice Address - Phone:808-320-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT333705-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP55636Medicare UPIN
UT0066994013Medicare ID - Type Unspecified