MEDICARE: DR. PAUL KENNETH GARDNER M.D.

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	207T00000X	Neurological Surgery Physician	378667-1205	UT

General Provider Information

NPI Number	:	1821012832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL KENNETH GARDNER M.D.

Provider Business Mailing Address
First Line	:	1055 N 300 W STE 400
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3359
Country	:	US
Telephone Number	:	801-357-7404
Fax Number	:	801-357-7587

Provider Business Practice Location Address
First Line	:	1055 N 300 W STE 400
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3359
Country	:	US
Telephone Number	:	801-357-7404
Fax Number	:	801-357-7587

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/09/2007

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