Healthcare Provider Details

I. General information

NPI: 1376873430
Provider Name (Legal Business Name): CODY WADE GARDNER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

PO BOX 4008
PORTLAND OR
97208-4008
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax:
Mailing address:
  • Phone: 503-372-2740
  • Fax: 503-372-2754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA 768
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: