Provider Demographics
NPI:1235752866
Name:BERGEN, PHILIP JACOB JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JACOB
Last Name:BERGEN
Suffix:JR
Gender:M
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 1:1129 WOLCOTT ST APT 3-12
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-1329
Mailing Address - Country:US
Mailing Address - Phone:203-947-4621
Mailing Address - Fax:
Practice Address - Street 1:60 OLD NEW MILFORD RD STE 3E
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-2414
Practice Address - Country:US
Practice Address - Phone:203-775-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-18
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23.004823363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant