Provider Demographics
NPI:1750157103
Name:GARDINER, JOSHUA (BS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:GARDINER
Suffix:
Gender:M
Credentials:BS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 AIRPORT RD APT 119
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80910-3007
Mailing Address - Country:US
Mailing Address - Phone:518-256-5507
Mailing Address - Fax:
Practice Address - Street 1:2200 BONFORTE BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-4901
Practice Address - Country:US
Practice Address - Phone:720-737-4856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAT.0002391207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine