Provider Demographics
NPI:1962466938
Name:GARDNER, TIMOTHY F (NP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:F
Last Name:GARDNER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4802 BROADWAY
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46408-4509
Practice Address - Country:US
Practice Address - Phone:219-887-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001772B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200496760Medicaid
IN164220OMedicare ID - Type Unspecified
IN703060RMedicare ID - Type Unspecified
IN703060RMedicare PIN
Q27140Medicare UPIN
IN164210OMedicare PIN
IN164220OMedicare PIN