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General NPI Number Information
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NPI Number | 1255114989
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Entity Type | Individual
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Provider Name | BRYAN WILLIAM GARDNER DPT, ATC, CSCS
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Gender | Male
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Dates
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Enumeration Date | 08/16/2023
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 2561 LAC DE VILLE BLVD STE 100
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City | ROCHESTER
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State | NY
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Zip | 14618-5645
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Country | US
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Telephone | 585-473-1290
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Fax | 585-869-5142
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Provider Business Mailing Address
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Address Line | 2561 LAC DE VILLE BLVD STE 100
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City | ROCHESTER
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State | NY
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Zip | 14618-5645
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Country | US
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Telephone | 585-869-5140
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Fax | 585-869-5142
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000005462
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 050727
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License Number State | NY
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