Provider Demographics
NPI:1376628107
Name:GARDNER, GREGORY C
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:C
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 KWINA RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9291
Mailing Address - Country:US
Mailing Address - Phone:360-384-0464
Mailing Address - Fax:
Practice Address - Street 1:2608 KWINA RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9291
Practice Address - Country:US
Practice Address - Phone:360-384-0464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00026866207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1376628107Medicaid
8500OtherINTERNAL ID-MOTOR VEHICLE ID
WA0231051OtherL&I
C35566Medicare UPIN
WA1376628107Medicaid