Basic Information
| Provider Information | |||||||||
| NPI: | 1437786316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BRYAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 WELLNESS PL APT 2134 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890112350 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3186 S MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029615000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 05/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OTH-008082 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | OT-2898 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.