Provider Demographics
NPI:1528001559
Name:BERGMAN, MARTHA B (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:B
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 1:309 NEW ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3654
Mailing Address - Country:US
Mailing Address - Phone:336-379-9708
Mailing Address - Fax:336-553-2085
Practice Address - Street 1:309 NEW ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3654
Practice Address - Country:US
Practice Address - Phone:336-379-9708
Practice Address - Fax:336-553-2085
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101823363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC561274347OtherCKA'S TAX ID #
NC8101862Medicaid
NC561274347OtherCKA'S TAX ID #
NC8101862Medicaid