MEDICARE: MISS JUANITA ANN GARDNER PA-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	363A00000X	Physician Assistant	MA001936L	PA

General Provider Information

NPI Number	:	1679907802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JUANITA ANN GARDNER PA-C

Provider Business Mailing Address
First Line	:	1505 RACE ST
Second Line	:	MAIL STOP 503
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1119
Country	:	US
Telephone Number	:	215-762-3083
Fax Number	:	215-762-1164

Provider Business Practice Location Address
First Line	:	1505 RACE ST
Second Line	:	MAIL STOP 503
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1119
Country	:	US
Telephone Number	:	215-762-3083
Fax Number	:	215-762-1164

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

Provider Enumeration Date	:	08/23/2013
Last Update Date	:	08/23/2013

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