Provider Demographics
NPI:1063589612
Name:GARDNER, LEE S (PA-C)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:S
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7510
Mailing Address - Country:US
Mailing Address - Phone:208-525-8448
Mailing Address - Fax:208-525-8118
Practice Address - Street 1:2725 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7510
Practice Address - Country:US
Practice Address - Phone:208-525-8448
Practice Address - Fax:208-525-8118
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-359363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP53155Medicare UPIN