Provider Demographics
NPI:1336290683
Name:BERGQUIST, NANCY (MD, DC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BERGQUIST
Suffix:
Gender:F
Credentials:MD, DC
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:WEIDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1740 DELL RANGE BLVD # H291
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4961
Mailing Address - Country:US
Mailing Address - Phone:719-357-8980
Mailing Address - Fax:
Practice Address - Street 1:214 E 23RD ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3748
Practice Address - Country:US
Practice Address - Phone:307-634-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13810A207Q00000X
CO4418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75-830Medicare PIN