Provider Demographics
NPI:1528063575
Name:GARDNER, GREGORY J
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9350 S 150 E
Mailing Address - Street 2:#460
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2702
Mailing Address - Country:US
Mailing Address - Phone:801-255-4999
Mailing Address - Fax:801-748-1865
Practice Address - Street 1:9350 S 150 E
Practice Address - Street 2:#460
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2702
Practice Address - Country:US
Practice Address - Phone:801-255-4999
Practice Address - Fax:801-748-1865
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104149-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT104149-2401OtherSTATE LICENSE