Healthcare Provider Details

I. General information

NPI: 1134113020
Provider Name (Legal Business Name): CLAIRE ELAINE GARDAM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: CLAIRE ELAINE AHLQUIST RN

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 3RD ST STE C
MALONE NY
12953-1305
US

IV. Provider business mailing address

19 MAPLE ST
CANTON NY
13617-1338
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-1015
  • Fax: 518-483-0430
Mailing address:
  • Phone: 315-386-3482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberF3600271
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: