Provider Demographics
NPI:1356485379
Name:BERGERON, MELISSA (PA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:BERGERON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 LOWELL ST
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4501
Mailing Address - Country:US
Mailing Address - Phone:978-783-5000
Mailing Address - Fax:978-313-8184
Practice Address - Street 1:323 LOWELL ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4501
Practice Address - Country:US
Practice Address - Phone:978-783-5000
Practice Address - Fax:978-313-8184
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1384363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP85878Medicare UPIN
MAAP1917Medicare PIN