Provider Demographics
NPI:1558301259
Name:BERGQUAM, NINA L (MD)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:L
Last Name:BERGQUAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:MICHELLE
Other - Last Name:LEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:1003 PROVIDENCE DR
Practice Address - Street 2:STE 110
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7521
Practice Address - Country:US
Practice Address - Phone:503-537-5900
Practice Address - Fax:503-537-5959
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD21625207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00250292OtherRR MEDICARE
ORP00250292OtherRR MEDICARE