Provider Demographics
NPI:1821012832
Name:GARDNER, PAUL KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:KENNETH
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1055 N 300 W STE 400
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3359
Mailing Address - Country:US
Mailing Address - Phone:801-357-7404
Mailing Address - Fax:801-357-7587
Practice Address - Street 1:1055 N 300 W STE 400
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3359
Practice Address - Country:US
Practice Address - Phone:801-357-7404
Practice Address - Fax:801-357-7587
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT378667-1205207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE83040Medicare UPIN