Provider Demographics
NPI:1407861115
Name:BERGERON, LY-LAN SCHOFIELD (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LY-LAN
Middle Name:SCHOFIELD
Last Name:BERGERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8220 BUCKNELL DR
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-6931
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6715 LITTLE RIVER TPKE
Practice Address - Street 2:201
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-3546
Practice Address - Country:US
Practice Address - Phone:703-914-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant