1528054335 NPI number — MRS. BARBARA A BERGERON FNP

Table of content: MRS. BARBARA A BERGERON FNP (NPI 1528054335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528054335 NPI number — MRS. BARBARA A BERGERON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGERON
Provider First Name:
BARBARA
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BILDERBACK
Provider Other First Name:
BARBARA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528054335
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2074 S 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97601-3372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-851-8110
Provider Business Mailing Address Fax Number:
541-851-8114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145 NE BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE CREEK
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97457-9039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-863-3146
Provider Business Practice Location Address Fax Number:
541-863-3226
Provider Enumeration Date:
09/27/2005

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: 363LF0000X , with the licence number:  79044326 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 209569 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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