Healthcare Provider Details

I. General information

NPI: 1710761812
Provider Name (Legal Business Name): DYLAN SEAN GARDNER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5606 PURA VIDA TRL
STILLWATER OK
74074-2692
US

IV. Provider business mailing address

5606 PURA VIDA TRL
STILLWATER OK
74074-2692
US

V. Phone/Fax

Practice location:
  • Phone: 405-880-1234
  • Fax:
Mailing address:
  • Phone: 405-880-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5704
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: