MEDICARE: MR. DONALD GLYN GARDNER II

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	214187	LA
2	363L00000X	Nurse Practitioner	214187	LA

General Provider Information

NPI Number	:	1578183208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DONALD GLYN GARDNER II

Provider Business Mailing Address
First Line	:	1000 CHINABERRY DR STE 502
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2462
Country	:	US
Telephone Number	:	318-232-2749
Fax Number	:	318-620-4031

Provider Business Practice Location Address
First Line	:	1000 CHINABERRY DR STE 502
Second Line	:
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-2462
Country	:	US
Telephone Number	:	318-232-2749
Fax Number	:	318-620-4031

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

Provider Enumeration Date	:	04/22/2020
Last Update Date	:	12/18/2025

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