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General NPI Number Information
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NPI Number | 1396943825
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Entity Type | Individual
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Provider Name | BRIAN KOWALLIS GARDNER DPM
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Gender | Male
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Dates
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Enumeration Date | 07/05/2007
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 210 W 300 N
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City | ROOSEVELT
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State | UT
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Zip | 84066-2336
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Country | US
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Telephone | 435-722-6163
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Fax | 435-722-9291
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Provider Business Mailing Address
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Address Line | 210 W 300 N
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City | ROOSEVELT
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State | UT
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Zip | 84066-2336
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Country | US
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Telephone | 435-722-6163
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Fax | 435-722-9291
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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 | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 6297901-0501
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License Number State | UT
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