Provider Demographics
NPI:1770948507
Name:GARDNER, TARA (CRNA)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9019 GENEVA CIR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-8583
Mailing Address - Country:US
Mailing Address - Phone:270-564-0793
Mailing Address - Fax:
Practice Address - Street 1:9019 GENEVA CIR
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-8583
Practice Address - Country:US
Practice Address - Phone:270-564-0793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010026367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered