Provider Demographics
NPI:1184699035
Name:GARDNER, MARY ELLEN (PA)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:MCCUTCHEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:509 BILTMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28801-4601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:509 BILTMORE AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4601
Practice Address - Country:US
Practice Address - Phone:828-213-1995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103308363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P39018Medicare UPIN
NC2759818AMedicare ID - Type Unspecified