Provider Demographics
NPI:1417468547
Name:GARDNER, ROSA LOUISE BREY (PA)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:LOUISE BREY
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ROSA
Other - Middle Name:
Other - Last Name:BREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1450 IDLEWILD DR UNIT 428
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1075
Mailing Address - Country:US
Mailing Address - Phone:406-599-1056
Mailing Address - Fax:
Practice Address - Street 1:1060 ORCHARD AVE UNIT N
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2997
Practice Address - Country:US
Practice Address - Phone:970-644-3740
Practice Address - Fax:970-644-3763
Is Sole Proprietor?:No
Enumeration Date:2017-10-16
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1902363A00000X
COPA.0005504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant