Provider Demographics
NPI:1043181332
Name:GARDNER, DYLAN JERAMIAH
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:JERAMIAH
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2008 AVENUE B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1941
Mailing Address - Country:US
Mailing Address - Phone:308-632-8016
Mailing Address - Fax:
Practice Address - Street 1:2614 W 42ND ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4802
Practice Address - Country:US
Practice Address - Phone:308-630-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-17
Last Update Date:2025-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider