Provider Demographics
NPI:1295376523
Name:BERGERON, EMILY MONTANA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:MONTANA
Last Name:BERGERON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4337 E 57TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-4237
Mailing Address - Country:US
Mailing Address - Phone:918-955-9302
Mailing Address - Fax:
Practice Address - Street 1:1417 W 78TH ST APT 1213
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-4633
Practice Address - Country:US
Practice Address - Phone:918-955-9302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-08
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4722363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical