Basic Information
| Provider Information | |||||||||
| NPI: | 1366770166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REEH | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1421 MAIN STREET | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302499995 | ||||||||
| FaxNumber: | 8302499868 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 MAIN STREET | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302499995 | ||||||||
| FaxNumber: | 8302499868 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2009 | ||||||||
| LastUpdateDate: | 12/27/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06471 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.