Provider Demographics
NPI:1336331065
Name:BERGTHOLD, DAVID N (MSN-ACNP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:N
Last Name:BERGTHOLD
Suffix:
Gender:M
Credentials:MSN-ACNP
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 1500
Mailing Address - Street 2:
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-1500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:54 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3050
Practice Address - Country:US
Practice Address - Phone:573-302-2287
Practice Address - Fax:573-302-2241
Is Sole Proprietor?:No
Enumeration Date:2007-08-16
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO139652363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1336331065Medicaid
MO135570015OtherMEDICARE PTAN
MOP00750268OtherRAIL ROAD MEDICARE