Provider Demographics
NPI:1497059729
Name:BERGMAN, MARY E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:E
Last Name:BERGMAN
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:KENNER ARMY HEALTH CLINIC
Mailing Address - Street 2:700 24TH ST
Mailing Address - City:FORT LEE
Mailing Address - State:VA
Mailing Address - Zip Code:23801
Mailing Address - Country:US
Mailing Address - Phone:804-734-9491
Mailing Address - Fax:
Practice Address - Street 1:KENNER ARMY HEALTH CLINIC
Practice Address - Street 2:700 24TH ST
Practice Address - City:FORT LEE
Practice Address - State:VA
Practice Address - Zip Code:23801
Practice Address - Country:US
Practice Address - Phone:804-734-9491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB2907193OtherDEA