Provider Demographics
NPI:1780611822
Name:GARDNER, JERRY L (RPA-C)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:GARDNER
Suffix:
Gender:M
Credentials:RPA-C
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:518-649-4094
Practice Address - Street 1:2125 RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-1135
Practice Address - Country:US
Practice Address - Phone:518-836-3030
Practice Address - Fax:518-836-3020
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY009170363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03810708Medicaid
NY03810708Medicaid