Provider Demographics
NPI:1033853593
Name:WAYLON CASEY BERGERON FNP-C, P.L.L.C
Entity Type:Organization
Organization Name:WAYLON CASEY BERGERON FNP-C, P.L.L.C
Other - Org Name:MEDPLUS MOBILE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYLON
Authorized Official - Middle Name:CASEY
Authorized Official - Last Name:BERGERON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:409-719-6035
Mailing Address - Street 1:230 TYLER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77630-2670
Mailing Address - Country:US
Mailing Address - Phone:409-719-6035
Mailing Address - Fax:
Practice Address - Street 1:3636 PROFESSIONAL DR STE 2
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-3848
Practice Address - Country:US
Practice Address - Phone:409-719-6035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care