Provider Demographics
NPI:1124034723
Name:BERGSMA, MARJORIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:A
Last Name:BERGSMA
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 1:1608 S J ST, FLOOR 2
Mailing Address - Street 2:0
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4930
Mailing Address - Country:US
Mailing Address - Phone:253-274-7503
Mailing Address - Fax:269-654-1192
Practice Address - Street 1:1608 S J ST FL 2
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4930
Practice Address - Country:US
Practice Address - Phone:253-274-7503
Practice Address - Fax:269-654-1192
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0205196OtherSTATE L&I
WA1042943Medicaid
WA0290553OtherSTATE L&I
WA8940935OtherSTATE CRIME VICTIMS
WA0289063OtherSTATE L&I
WA8357279Medicaid
WA0290553OtherSTATE L&I
WA8357279Medicaid
Q63458Medicare UPIN