Provider Demographics
NPI:1366770166
Name:GARDNER, ELIZABETH MARIE (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:REEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1421 MAIN STREET
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3322
Mailing Address - Country:US
Mailing Address - Phone:830-249-9995
Mailing Address - Fax:830-249-9868
Practice Address - Street 1:1421 MAIN STREET
Practice Address - Street 2:SUITE 111
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-3322
Practice Address - Country:US
Practice Address - Phone:830-249-9995
Practice Address - Fax:830-249-9868
Is Sole Proprietor?:No
Enumeration Date:2009-12-07
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant