MEDICARE: MR. THOMAS CHARLES GARDNER APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN	MO

General Provider Information

NPI Number	:	1811153729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS CHARLES GARDNER APN

Provider Business Mailing Address
First Line	:	2642 STATE ROUTE 76
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-8254
Country	:	US
Telephone Number	:	417-469-5124
Fax Number	:	417-469-1165

Provider Business Practice Location Address
First Line	:	2642 STATE ROUTE 76
Second Line	:
City	:	WILLOW SPRINGS
State	:	MO
Zip	:	65793-8254
Country	:	US
Telephone Number	:	417-469-5124
Fax Number	:	417-469-1165

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2008
Last Update Date	:	06/29/2011

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