Basic Information
| Provider Information | |||||||||
| NPI: | 1528054152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | VANCE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 N DEKALB ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281504188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044848001 | ||||||||
| FaxNumber: | 7044842485 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 N DEKALB ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SHELBY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281504188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7044848001 | ||||||||
| FaxNumber: | 7044842485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 08/19/2011 | ||||||||
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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 | 363LF0000X | 201403 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.