Provider Demographics
NPI:1922039270
Name:GARDNER, TERESA DIANNE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:DIANNE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-294-7172
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-265-2810
Practice Address - Fax:214-265-2820
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX224312367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX89940UOtherBCBS
TX89781UOtherBCBSTX
TX86036UOtherBCBSTX
TX088673103Medicaid
TXP00705780OtherMEDICARE RAILROAD PROVIDER
TX86036UOtherBCBSTX
TX8L8465Medicare PIN
TX89940UOtherBCBS
TX088673103Medicaid