Provider Demographics
NPI:1336211572
Name:GARDNER, MELODYE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MELODYE
Middle Name:ANN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 SOUTH LAUREL
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648
Mailing Address - Country:US
Mailing Address - Phone:830-875-6399
Mailing Address - Fax:830-875-6398
Practice Address - Street 1:9670 RANCH ROAD 12
Practice Address - Street 2:
Practice Address - City:WIMBERLEY
Practice Address - State:TX
Practice Address - Zip Code:78676-5238
Practice Address - Country:US
Practice Address - Phone:512-847-6789
Practice Address - Fax:512-847-7968
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2017-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA05019OtherPA LICENSE