Basic Information
| Provider Information | |||||||||
| NPI: | 1164683413 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | CLARK | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 N CENTER ST STE 800 | ||||||||
| Address2: | |||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840437406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0189901911 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4401 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844033195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013872800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2008 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 20A12319 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.