Provider Demographics
NPI:1043840721
Name:GARDNER, JOHANNA ROSSITCH (PA-C)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:ROSSITCH
Last Name:GARDNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JOHANNA
Other - Middle Name:ISABELLE
Other - Last Name:ROSSITCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:501 S SHARON AMITY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-0035
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-0035
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09716363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical