Provider Demographics
NPI:1265407217
Name:GARDNER, ROBYN M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ROBYN
Middle Name:M
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:ROBYN
Other - Middle Name:E
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 CELEBRATION PL
Mailing Address - Street 2:SUITE A140
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4970
Mailing Address - Country:US
Mailing Address - Phone:407-303-4602
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:SUITE A140
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-303-4602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004155363AS0400X
FLPA9106706363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ04035Medicare UPIN
97WCFFWMedicare ID - Type Unspecified