Provider Demographics
NPI:1407738529
Name:GARDNER, DAVID J (BA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4541 TEAL LN
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:WY
Mailing Address - Zip Code:82053-9745
Mailing Address - Country:US
Mailing Address - Phone:307-677-3664
Mailing Address - Fax:
Practice Address - Street 1:4541 TEAL LN
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:WY
Practice Address - Zip Code:82053-9745
Practice Address - Country:US
Practice Address - Phone:307-677-3664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-21
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator