Provider Demographics
NPI:1093991739
Name:BERGER, AMY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:BERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 MAPLE LANE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:WI
Mailing Address - Zip Code:54806
Mailing Address - Country:US
Mailing Address - Phone:715-685-6010
Mailing Address - Fax:719-368-6872
Practice Address - Street 1:1615 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806
Practice Address - Country:US
Practice Address - Phone:715-685-6010
Practice Address - Fax:719-368-6872
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2775363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO305010Medicaid
CO78601371Medicaid
COOTH000Medicare UPIN
COCS2008Medicare PIN
COCO305010Medicaid
CO970003420Medicare PIN