Provider Demographics
NPI:1164446431
Name:BERGERON, CAROL VERONICA (ANP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:VERONICA
Last Name:BERGERON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 OLEETA RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-2507
Mailing Address - Country:US
Mailing Address - Phone:631-331-2129
Mailing Address - Fax:
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6207
Practice Address - Fax:631-548-6223
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF 301900-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health