Provider Demographics
NPI:1790186922
Name:GARDNER, BENJAMIN JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOHN
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 1:8322 BELLONA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2065
Mailing Address - Country:US
Mailing Address - Phone:410-337-7900
Mailing Address - Fax:410-337-5321
Practice Address - Street 1:8322 BELLONA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2065
Practice Address - Country:US
Practice Address - Phone:410-337-7900
Practice Address - Fax:410-337-5321
Is Sole Proprietor?:No
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005516363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0005516OtherPA-C LICENSE