MEDICARE: DR. FREDA EVA GARDNER MD

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	207R00000X	Internal Medicine Physician	MD00045867	WA

General Provider Information

NPI Number	:	1750378279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FREDA EVA GARDNER MD

Provider Business Mailing Address
First Line	:	1611 ORION PL
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-8836
Country	:	US
Telephone Number	:	720-340-4293
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 ORION PL
Second Line	:
City	:	LONGMONT
State	:	CO
Zip	:	80504-8836
Country	:	US
Telephone Number	:	720-340-4293
Fax Number	:

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

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	10/25/2011

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