Healthcare Provider Details

I. General information

NPI: 1306821756
Provider Name (Legal Business Name): TRESSA K GARDNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 N PERRY ST
PONTIAC MI
48342-2217
US

IV. Provider business mailing address

50 N PERRY ST
PONTIAC MI
48342-2217
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-5327
  • Fax: 248-338-5129
Mailing address:
  • Phone: 248-338-5327
  • Fax: 248-338-5129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number5101012299
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: