Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 222099 | NY |
NPI | 1144394776 |
---|---|
Provider Name | Dr. Traci Furbert Gardner |
First Address | Thornwood, NY 10594-1143 |
Second Address | Thornwood, NY 10594-1143 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/11/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H48930 | (02) | NY |