MEDICARE: DANIEL JAE GARDNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	199	WY

General Provider Information

NPI Number	:	1235005174
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL JAE GARDNER

Provider Business Mailing Address
First Line	:	PO BOX 1062
Second Line	:
City	:	RIVERTON
State	:	WY
Zip	:	82501-0119
Country	:	US
Telephone Number	:	307-856-8090
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 GREAT PLAINS LOOP
Second Line	:
City	:	ARAPAHOE
State	:	WY
Zip	:	82510-8903
Country	:	US
Telephone Number	:	307-856-8090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2025
Last Update Date	:	10/16/2025

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