Provider Demographics
NPI:1477068294
Name:BERGESON, MICHAEL G (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:BERGESON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 W 1300 NORTH CIR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1400
Mailing Address - Country:US
Mailing Address - Phone:804-335-7421
Mailing Address - Fax:
Practice Address - Street 1:136 W 1300 NORTH CIR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-1400
Practice Address - Country:US
Practice Address - Phone:804-335-7421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001264680367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered