Provider Demographics
NPI:1144699075
Name:GARDNER, MICHAEL (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21756 STATE ROAD 54
Mailing Address - Street 2:STE 102
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-2905
Mailing Address - Country:US
Mailing Address - Phone:813-418-7350
Mailing Address - Fax:
Practice Address - Street 1:3903 NORTHDALE BLVD
Practice Address - Street 2:SUITE 111W
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-1864
Practice Address - Country:US
Practice Address - Phone:813-418-7350
Practice Address - Fax:813-265-2504
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 30795225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist