Basic Information
| Provider Information | |||||||||
| NPI: | 1528379518 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | EILEEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5099449644 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 E COLUMBIA AVE | ||||||||
| Address2: | |||||||||
| City: | COLVILLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 991143354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096843701 | ||||||||
| FaxNumber: | 5096845817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2010 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD60301756 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | RES000 | 01 | WA | RES000 | OTHER |