Healthcare Provider Details

I. General information

NPI: 1962466938
Provider Name (Legal Business Name): TIMOTHY F GARDNER NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 BROADWAY
GARY IN
46408-4509
US

IV. Provider business mailing address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

V. Phone/Fax

Practice location:
  • Phone: 219-887-4950
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001772B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: