Basic Information
| Provider Information | |||||||||
| NPI: | 1790186922 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8322 BELLONA AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212042065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103377900 | ||||||||
| FaxNumber: | 4103375321 | ||||||||
| Practice Location | |||||||||
| Address1: | 8322 BELLONA AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TOWSON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212042065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103377900 | ||||||||
| FaxNumber: | 4103375321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2014 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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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 | 363AM0700X | C0005516 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | C0005516 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | C0005516 | 01 | MD | PA-C LICENSE | OTHER |