Provider Demographics
NPI:1437641131
Name:BERGQUIST, ERIC AFTON
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:AFTON
Last Name:BERGQUIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2820
Mailing Address - Country:US
Mailing Address - Phone:415-252-4787
Mailing Address - Fax:415-655-7254
Practice Address - Street 1:1060 HOWARD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2820
Practice Address - Country:US
Practice Address - Phone:415-252-4787
Practice Address - Fax:415-655-7254
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker