Basic Information
| Provider Information | |||||||||
| NPI: | 1275913279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | PHILLIP | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7987 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366700987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516330573 | ||||||||
| FaxNumber: | 2516337367 | ||||||||
| Practice Location | |||||||||
| Address1: | 8725 COUNTY ROAD 64 | ||||||||
| Address2: | |||||||||
| City: | DAPHNE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516251370 | ||||||||
| FaxNumber: | 2516251380 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-122937 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 1-122937 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 222164 | 05 | AL | MEDICAID | 223477 | 05 | AL | MEDICAID | 179179 | 05 | AL | MEDICAID | 511-70269 | 01 | AL | BCBS | OTHER | 512-05548 | 01 | AL | BCBS | OTHER | Z33078 | 01 | AL | VIVA HEALTH | OTHER | 03323279 | 01 | MS | MS MEDICAID | OTHER | 4992223 | 01 | AL | AETNA | OTHER | 511-95547 | 01 | AL | BCBS | OTHER | 213045 | 05 | AL | MEDICAID | 221246 | 05 | AL | MEDICAID | 511-67959 | 01 | AL | BCBS | OTHER | 214334 | 05 | AL | MEDICAID | 511-70270 | 01 | AL | BCBS | OTHER | P01572739 | 01 | AL | RR MEDICARE | OTHER | 10138I3499 | 01 | AL | MEDICARE | OTHER | 512-05546 | 01 | AL | BCBS | OTHER | 5581031 | 01 | AL | UHC | OTHER |