Provider Demographics
NPI:1306209721
Name:BERGERON, WAYLON CASEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:WAYLON
Middle Name:CASEY
Last Name:BERGERON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 FOLSOM DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-7269
Mailing Address - Country:US
Mailing Address - Phone:409-835-0524
Mailing Address - Fax:409-835-0632
Practice Address - Street 1:6450 FOLSOM DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7269
Practice Address - Country:US
Practice Address - Phone:409-835-0524
Practice Address - Fax:409-835-0632
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-02
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130665363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily