Provider Demographics
NPI:1700079662
Name:GARDNER, NATHAN JAMES (PA)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:JAMES
Last Name:GARDNER
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Gender:M
Credentials:PA
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Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:81 MILLER RD
Practice Address - Street 2:SUITE 800
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-4035
Practice Address - Country:US
Practice Address - Phone:518-477-2167
Practice Address - Fax:518-477-5182
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2021-05-19
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Provider Licenses
StateLicense IDTaxonomies
NY23012060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01436135Medicaid
NYJ400053940Medicare PIN