Provider Demographics
NPI:1912974858
Name:GARDNER, PATRICK MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3200 PLEASANT VALLEY RD
Mailing Address - Street 2:DEPARTMENT OF PATHOLOGY
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9274
Mailing Address - Country:US
Mailing Address - Phone:262-836-7300
Mailing Address - Fax:262-334-8484
Practice Address - Street 1:3200 PLEASANT VALLEY RD
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9274
Practice Address - Country:US
Practice Address - Phone:262-836-7300
Practice Address - Fax:262-334-8484
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI35568-020207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32421900Medicaid
WI1912974858Medicaid
WI1912974858Medicaid
WA32421900Medicaid
WI736012374Medicare PIN
WI680861172Medicare PIN
WI220023994Medicare PIN