Basic Information
| Provider Information | |||||||||
| NPI: | 1376654798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8055 O ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685102580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024210896 | ||||||||
| FaxNumber: | 4024210945 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 E HIGHWAY 33 | ||||||||
| Address2: | |||||||||
| City: | CRETE | ||||||||
| State: | NE | ||||||||
| PostalCode: | 683332547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028263222 | ||||||||
| FaxNumber: | 4028263228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/28/2008 | ||||||||
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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 | 207Q00000X | 13075 | NE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1856 | 01 | NE | MIDLANDS CHOICE | OTHER | 01-04212 | 01 | NE | UHC | OTHER | 06233 | 01 | NE | BCBS | OTHER |