Provider Demographics
NPI:1205877727
Name:GARDNER, BEN D (ARNP)
Entity type:Individual
Prefix:MR
First Name:BEN
Middle Name:D
Last Name:GARDNER
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 EASTSIDE ST SE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-7304
Mailing Address - Country:US
Mailing Address - Phone:360-943-5127
Mailing Address - Fax:360-754-2516
Practice Address - Street 1:1100 EASTSIDE ST SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-7304
Practice Address - Country:US
Practice Address - Phone:360-943-5127
Practice Address - Fax:360-754-2516
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00158155363L00000X
WAAP30007002363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9645300Medicaid
WA8854680Medicare ID - Type Unspecified
WAQ48246Medicare UPIN