Provider Demographics
NPI:1528821642
Name:GARDNER, JACOB RYAN (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RYAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:701 94TH AVE N STE 250
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2448
Mailing Address - Country:US
Mailing Address - Phone:727-321-3854
Mailing Address - Fax:
Practice Address - Street 1:18167 US HIGHWAY 19 N STE 150
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-6566
Practice Address - Country:US
Practice Address - Phone:727-321-3854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9118395363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical