Healthcare Provider Details

I. General information

NPI: 1114909439
Provider Name (Legal Business Name): PAUL MATTHEW GARDNER MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 8TH AVE SUITE 8
PLATTSMOUTH NE
68048-2367
US

IV. Provider business mailing address

2380 8TH AVE SUITE 8
PLATTSMOUTH NE
68048-2367
US

V. Phone/Fax

Practice location:
  • Phone: 402-296-3433
  • Fax: 402-296-3531
Mailing address:
  • Phone: 402-296-3433
  • Fax: 402-296-3531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1922
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: