1508954421 NPI number — MR. JOHN WESLEY GARDNER IV RN

Table of content: MR. JOHN WESLEY GARDNER IV RN (NPI 1508954421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508954421 NPI number — MR. JOHN WESLEY GARDNER IV RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GARDNER
Provider First Name:
JOHN
Provider Middle Name:
WESLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
IV
Provider Credential Text:
RN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508954421
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3441 CARSON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-647-9704
Provider Business Mailing Address Fax Number:
530-644-8420

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1080 MARSHALL WAY
Provider Second Line Business Practice Location Address:
MARSHALL HOSPITAL
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-1441
Provider Business Practice Location Address Fax Number:
530-622-8655
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WR0006X , with the licence number:  468480 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com