Provider Demographics
NPI:1013939024
Name:GARDNER, ELLEN F (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:F
Last Name:GARDNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:200 SOUTH 4200 WEST
Mailing Address - City:PAROWAN
Mailing Address - State:UT
Mailing Address - Zip Code:84761-1330
Mailing Address - Country:US
Mailing Address - Phone:435-477-0133
Mailing Address - Fax:435-477-0143
Practice Address - Street 1:200 SOUTH 4200 WEST
Practice Address - Street 2:
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761
Practice Address - Country:US
Practice Address - Phone:435-477-0133
Practice Address - Fax:435-477-0143
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT881786891205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000063254Medicare PIN