Provider Demographics
NPI:1992461859
Name:GARDINER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GARDINER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 S WINSTON AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2079
Mailing Address - Country:US
Mailing Address - Phone:918-402-2258
Mailing Address - Fax:
Practice Address - Street 1:1729 S BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4807
Practice Address - Country:US
Practice Address - Phone:918-599-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist