MEDICARE: CASEY J GARDNER P.A.C.

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	363AS0400X	Surgical Physician Assistant	10000672A	IN
2	363AS0400X	Surgical Physician Assistant	0003579	CO
3	363AM0700X	Medical Physician Assistant	10000672A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	151020TTTT	OTHER	IN	MEDICARE PTAN NUMBER
2	151020	OTHER	CO	MEDICARE PTAN
4	P00841261	OTHER	IN	RAILROAD MEDICARE PTAN NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629059878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY J GARDNER P.A.C.

Provider Business Mailing Address
First Line	:	575 RIVERGATE LN UNIT 105
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-7490
Country	:	US
Telephone Number	:	970-259-3020
Fax Number	:	970-259-9766

Provider Business Practice Location Address
First Line	:	575 RIVERGATE LN UNIT 105
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-7490
Country	:	US
Telephone Number	:	970-259-3020
Fax Number	:	970-259-9766

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

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	02/19/2024

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Directions to “ CASEY J GARDNER P.A.C.” Practice Location

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