Provider Demographics
NPI:1285258731
Name:GARDNER, JEFF HARRY WYATT (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:HARRY WYATT
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:WYATT
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, MPAS
Mailing Address - Street 1:1333 W 5TH ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-2752
Mailing Address - Country:US
Mailing Address - Phone:307-675-5850
Mailing Address - Fax:
Practice Address - Street 1:1435 BURTON ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-2723
Practice Address - Country:US
Practice Address - Phone:307-675-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-01
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant