Provider Demographics
NPI:1285963777
Name:GARDNER, TODD A (PTA)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 NORTH 830 WEST
Mailing Address - Street 2:
Mailing Address - City:WEST BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84087
Mailing Address - Country:US
Mailing Address - Phone:801-916-6566
Mailing Address - Fax:801-295-6568
Practice Address - Street 1:2233 NORTH 830 WEST
Practice Address - Street 2:
Practice Address - City:WEST BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84087
Practice Address - Country:US
Practice Address - Phone:801-916-6566
Practice Address - Fax:801-295-6568
Is Sole Proprietor?:No
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2852642402225200000X
IDPTA-266225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant