Provider Demographics
NPI:1003130402
Name:BERGEN, AILEEN ELIZABETH (PA)
Entity Type:Individual
Prefix:MRS
First Name:AILEEN
Middle Name:ELIZABETH
Last Name:BERGEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AILEEN
Other - Middle Name:ELIZABETH
Other - Last Name:WAWRZASZEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:230 CLEARFIELD AVE STE 124
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1832
Mailing Address - Country:US
Mailing Address - Phone:757-321-3383
Mailing Address - Fax:573-213-3330
Practice Address - Street 1:1800 CAMELOT DR STE 300
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2440
Practice Address - Country:US
Practice Address - Phone:757-321-3300
Practice Address - Fax:757-321-3330
Is Sole Proprietor?:No
Enumeration Date:2010-03-15
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003549363A00000X, 363AM0700X
NY013890363A00000X
SC2508363AS0400X
TNPA2523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003130402Medicaid
SC3467PAMedicaid