Healthcare Provider Details

I. General information

NPI: 1467980177
Provider Name (Legal Business Name): KIRSTEN GARDNER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RIVERSIDE CIR STE 300
ROANOKE VA
24016-4962
US

IV. Provider business mailing address

7847 FOREST EDGE DR
ROANOKE VA
24018-5844
US

V. Phone/Fax

Practice location:
  • Phone: 540-581-0238
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number0116033802
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116033802
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: