Provider Demographics
NPI:1568915502
Name:BERGLUND, NODIA
Entity Type:Individual
Prefix:
First Name:NODIA
Middle Name:
Last Name:BERGLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NODIA
Other - Middle Name:
Other - Last Name:LIPPERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2905 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-7316
Mailing Address - Country:US
Mailing Address - Phone:605-341-7337
Mailing Address - Fax:
Practice Address - Street 1:2905 5TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7316
Practice Address - Country:US
Practice Address - Phone:605-341-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant