Provider Demographics
NPI:1013536184
Name:GARDNER, AUSTIN BLAKE
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:BLAKE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
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 649
Mailing Address - Street 2:
Mailing Address - City:TWIN PEAKS
Mailing Address - State:CA
Mailing Address - Zip Code:92391-0649
Mailing Address - Country:US
Mailing Address - Phone:909-273-7429
Mailing Address - Fax:
Practice Address - Street 1:3701 MARKET ST STE 800
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5502
Practice Address - Country:US
Practice Address - Phone:215-662-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2024-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT232179207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology