Provider Demographics
NPI:1457480279
Name:BERGROOS, ROSEMARY EDITH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ROSEMARY
Middle Name:EDITH
Last Name:BERGROOS
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 1:350 LOUISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2130
Mailing Address - Country:US
Mailing Address - Phone:406-293-0133
Mailing Address - Fax:
Practice Address - Street 1:350 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2130
Practice Address - Country:US
Practice Address - Phone:406-293-0133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0430814Medicaid
MTP44166Medicare UPIN