Provider Demographics
NPI:1174291322
Name:BERGAMASCHI, SHAWN EVERETT (CHA-T)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:EVERETT
Last Name:BERGAMASCHI
Suffix:
Gender:M
Credentials:CHA-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SCOW JOHN ROAD
Mailing Address - Street 2:
Mailing Address - City:WHITE MOUNTAIN
Mailing Address - State:AK
Mailing Address - Zip Code:99784
Mailing Address - Country:US
Mailing Address - Phone:907-638-3311
Mailing Address - Fax:907-638-2007
Practice Address - Street 1:1000 GREG KRUSHEK AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762-9976
Practice Address - Country:US
Practice Address - Phone:907-638-3311
Practice Address - Fax:907-638-2007
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHA-TOtherCHA-T