Provider Demographics
NPI:1538241120
Name:GARDNER, CHARLOTTE P (PAC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:P
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5234 SW PHILOMATH BOULEVARD
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1042
Practice Address - Country:US
Practice Address - Phone:541-768-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPA201363A00000X
OR159864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKS36471Medicare UPIN