Provider Demographics
NPI:1316943343
Name:GARDNER, MARSHALL (PA-C)
Entity type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
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 1:600 ROBBINS RD
Mailing Address - Street 2:STE 300
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4565
Mailing Address - Country:US
Mailing Address - Phone:208-489-4016
Mailing Address - Fax:208-489-4015
Practice Address - Street 1:600 ROBBINS RD
Practice Address - Street 2:STE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4565
Practice Address - Country:US
Practice Address - Phone:208-489-4016
Practice Address - Fax:208-489-4015
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-443363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP48884Medicare UPIN