Basic Information
| Provider Information | |||||||||
| NPI: | 1942645536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WONNEBERGER | ||||||||
| OtherFirstName: | KATHERINE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3400 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156622200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2500 DEKALB PIKE STE 301 | ||||||||
| Address2: | |||||||||
| City: | EAST NORRITON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194012007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849659566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2013 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD455119 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.