Provider Demographics
NPI:1245274133
Name:GARDNER, WILLIAM VAUGHN (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:VAUGHN
Last Name:GARDNER
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2561 MOUNTAIN VILLAGE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-376-2411
Mailing Address - Fax:907-631-0647
Practice Address - Street 1:2561 MOUNTAIN VILLAGE DR
Practice Address - Street 2:SUITE F
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-290-3760
Practice Address - Fax:907-631-0647
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2025-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2454207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2454Medicaid
200012546OtherMDCR RAILROAD
AKK00WCJQDBMedicare PIN