Provider Demographics
NPI:1447264841
Name:GARDNER, JON B (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:B
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:380 CHASE ST
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-525-8110
Practice Address - Fax:509-522-5743
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1447264841Medicaid
WA1447264841Medicaid