Provider Demographics
NPI:1114015252
Name:BERGERON, ROBERT PAUL (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PAUL
Last Name:BERGERON
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:PO BOX 50360
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79159-0360
Mailing Address - Country:US
Mailing Address - Phone:806-236-1841
Mailing Address - Fax:
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-354-1370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX459487367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83021UOtherBLUE CROSS BLUE SHIELD
TX83021UOtherBLUE CROSS BLUE SHIELD