Healthcare Provider Details

I. General information

NPI: 1689701260
Provider Name (Legal Business Name): SHANNON L GARDINER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 S VANGUARD WAY STE 200
MERIDIAN ID
83642-8542
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2895
  • Fax: 208-809-2896
Mailing address:
  • Phone: 208-985-1423
  • Fax: 208-955-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA403
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-403
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: