Provider Demographics
NPI:1457329575
Name:BERGE, NICOLE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:BERGE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:GOSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16328 NIEMAN RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-6421
Mailing Address - Country:US
Mailing Address - Phone:630-854-2931
Mailing Address - Fax:
Practice Address - Street 1:7450 KESSLER ST STE 203
Practice Address - Street 2:
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2519
Practice Address - Country:US
Practice Address - Phone:913-676-7585
Practice Address - Fax:913-676-8189
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001444363AM0700X
KS15-01168363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical