Basic Information
| Provider Information | |||||||||
| NPI: | 1386885648 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | GLENN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 370 | ||||||||
| Address2: | |||||||||
| City: | BUTLER | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647300370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6602007033 | ||||||||
| FaxNumber: | 6602007015 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 E. MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 647209207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162972640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 08/01/2011 | ||||||||
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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 | 363A00000X | 1706 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2011020458 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.