Provider Demographics
NPI:1962768366
Name:GARDNER, ABIGAIL B (PA-C)
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:B
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 766351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:9880 ANGIES WAY STE 250
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2865
Practice Address - Country:US
Practice Address - Phone:502-394-6341
Practice Address - Fax:502-394-6340
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC095363A00000X
KYPA1708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50040098OtherPASSPORT - NOTC
KYP01205327OtherMEDICARE - RR
KY7100205790Medicaid
KY000000759487OtherANTHEM - NOS
KY135234OtherSIHO - NOTC
KYK043060Medicare PIN