Provider Demographics
NPI:1508003575
Name:BERGNER, MARK W (RN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:BERGNER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 KINOOLE ST
Mailing Address - Street 2:BUILDING B
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-7206
Mailing Address - Country:US
Mailing Address - Phone:808-934-3214
Mailing Address - Fax:808-961-4909
Practice Address - Street 1:1178 KINOOLE ST
Practice Address - Street 2:BUILDING B
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-7206
Practice Address - Country:US
Practice Address - Phone:808-934-3214
Practice Address - Fax:808-961-4909
Is Sole Proprietor?:No
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-64478163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse