Provider Demographics
NPI:1629059878
Name:GARDNER, CASEY J (PAC)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:J
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 1:575 RIVERGATE LN UNIT 105
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7490
Mailing Address - Country:US
Mailing Address - Phone:970-259-3020
Mailing Address - Fax:970-259-9766
Practice Address - Street 1:575 RIVERGATE LN UNIT 105
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7490
Practice Address - Country:US
Practice Address - Phone:970-259-3020
Practice Address - Fax:970-259-9766
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000672A363AS0400X, 363AM0700X
CO0003579363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN151020TTTTOtherMEDICARE PTAN NUMBER
CO151020OtherMEDICARE PTAN
CO9000178409Medicaid
INP00841261OtherRAILROAD MEDICARE PTAN NUMBER
IN959090009Medicare PIN