Provider Demographics
NPI:1003578568
Name:BERGEN, MARSHALL BARR (CRNA)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:BARR
Last Name:BERGEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 E BEACON DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2674
Mailing Address - Country:US
Mailing Address - Phone:480-282-2011
Mailing Address - Fax:
Practice Address - Street 1:4605 E ELWOOD ST STE 500
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-1978
Practice Address - Country:US
Practice Address - Phone:480-256-1518
Practice Address - Fax:480-304-3446
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN192249163W00000X
AZ269219367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ269219OtherARIZONA NURSING BOARD