Healthcare Provider Details

I. General information

NPI: 1932638533
Provider Name (Legal Business Name): GARETH LANCE GARDINER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 STOCKYARD RD STE I-200
MISSOULA MT
59808-1548
US

IV. Provider business mailing address

200 HAWKINS DR DEPT OF
IOWA CITY IA
52242-1009
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-8420
  • Fax: 406-541-8430
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR-10965
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMED-PHYS-LIC-97106
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: