Provider Demographics
NPI:1194110262
Name:GARDNER, STEPHEN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:STEPHEN
Other - Middle Name:MICHAEL
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:345 N 101ST ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9113
Mailing Address - Country:US
Mailing Address - Phone:310-760-2237
Mailing Address - Fax:
Practice Address - Street 1:14701 179TH AVE SE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1108
Practice Address - Country:US
Practice Address - Phone:360-794-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-05
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60813210207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty