Healthcare Provider Details

I. General information

NPI: 1700516978
Provider Name (Legal Business Name): LAUREL M GARDNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 S MIDDLETON RD
NAMPA ID
83651-1526
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-505-2800
  • Fax: 208-505-2801
Mailing address:
  • Phone: 208-381-8752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2660
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: