Provider Demographics
NPI:1558300665
Name:BERGEN, SOPHEA (PA-C)
Entity Type:Individual
Prefix:
First Name:SOPHEA
Middle Name:
Last Name:BERGEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SOPHEA
Other - Middle Name:
Other - Last Name:JOHANSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6719 ALVARADO RD STE 308
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5268
Mailing Address - Country:US
Mailing Address - Phone:619-265-7912
Mailing Address - Fax:619-265-7922
Practice Address - Street 1:6719 ALVARADO RD STE 308
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5268
Practice Address - Country:US
Practice Address - Phone:619-265-7912
Practice Address - Fax:619-265-7922
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA972363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant