Provider Demographics
NPI:1104121359
Name:GARDNER, ERIC LAWRENCE
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LAWRENCE
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 1:872 JOYLENE DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-8930
Mailing Address - Country:US
Mailing Address - Phone:585-478-7313
Mailing Address - Fax:
Practice Address - Street 1:872 JOYLENE DR
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-8930
Practice Address - Country:US
Practice Address - Phone:585-478-7313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608378163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse