Provider Demographics
NPI:1275103459
Name:BERGUM, RY WILLIS (PMHNP)
Entity Type:Individual
Prefix:
First Name:RY
Middle Name:WILLIS
Last Name:BERGUM
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18100 GOLDEN BEAR TRCE APT 402
Mailing Address - Street 2:
Mailing Address - City:MOSELEY
Mailing Address - State:VA
Mailing Address - Zip Code:23120-1884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5525 CATAWBA HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CATAWBA
Practice Address - State:VA
Practice Address - Zip Code:24070-2115
Practice Address - Country:US
Practice Address - Phone:540-375-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181720363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health