Provider Demographics
NPI:1306018148
Name:BERGERON, DIANE E (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:E
Last Name:BERGERON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8307
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77387-8307
Mailing Address - Country:US
Mailing Address - Phone:281-296-8788
Mailing Address - Fax:281-419-1291
Practice Address - Street 1:1111 MEDICAL PLAZA DR
Practice Address - Street 2:250
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-3240
Practice Address - Country:US
Practice Address - Phone:281-296-8788
Practice Address - Fax:281-419-1291
Is Sole Proprietor?:No
Enumeration Date:2008-04-01
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX626794363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193009102Medicaid
TX154240902Medicaid
TX8K6022Medicare PIN
TX8K8782Medicare PIN