Provider Demographics
NPI:1235207143
Name:BERGLUND, MEAGHAN MORIAH (PA)
Entity Type:Individual
Prefix:
First Name:MEAGHAN
Middle Name:MORIAH
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEAGHAN
Other - Middle Name:MORIAH
Other - Last Name:BAACKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4990 ROCKLIN RD
Mailing Address - Street 2:#100
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-4315
Mailing Address - Country:US
Mailing Address - Phone:916-788-4484
Mailing Address - Fax:916-218-6252
Practice Address - Street 1:4990 ROCKLIN RD
Practice Address - Street 2:#100
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-4315
Practice Address - Country:US
Practice Address - Phone:916-788-4484
Practice Address - Fax:916-218-6252
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant