1750890554 NPI number — ASHTON MAKAILA BERGH FNP - BC, C

Table of content: ASHTON MAKAILA BERGH FNP - BC, C (NPI 1750890554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750890554 NPI number — ASHTON MAKAILA BERGH FNP - BC, C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERGH
Provider First Name:
ASHTON
Provider Middle Name:
MAKAILA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP - BC, C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHADFAR
Provider Other First Name:
ASHTON
Provider Other Middle Name:
MAKAILA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1750890554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3990 W 255TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISBURG
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66053-6293
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-548-6230
Provider Business Mailing Address Fax Number:
877-492-3737

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10951 LAKEVIEW AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LENEXA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66219-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-432-7200
Provider Business Practice Location Address Fax Number:
877-492-3737
Provider Enumeration Date:
09/25/2017

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:  77893 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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