Provider Demographics
NPI:1043255318
Name:BERGERON-JOHNSON, ROSEMARY (PAC)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:BERGERON-JOHNSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 MASSAPOAG AVE
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2713
Mailing Address - Country:US
Mailing Address - Phone:478-719-8328
Mailing Address - Fax:
Practice Address - Street 1:110 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3315
Practice Address - Country:US
Practice Address - Phone:509-575-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S33055Medicare UPIN