Provider Demographics
NPI:1407838824
Name:BERG, JOHN DENNIS (CRNA APNP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DENNIS
Last Name:BERG
Suffix:
Gender:M
Credentials:CRNA APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4936 ORMOND BEACH CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-9342
Mailing Address - Country:US
Mailing Address - Phone:920-410-0472
Mailing Address - Fax:920-235-8915
Practice Address - Street 1:4936 ORMOND BEACH CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-9342
Practice Address - Country:US
Practice Address - Phone:920-410-0472
Practice Address - Fax:920-235-8915
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67892-030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI67892-030OtherNURSING LICENSE
383-033OtherAPNP
WI31946OtherAANA CERTIFICATION
WI43299100Medicaid
WI67892-030OtherNURSING LICENSE
WI21651Medicare ID - Type Unspecified