Provider Demographics
NPI:1609829274
Name:BERGIN, CAMERON MICHAEL (PAC)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:MICHAEL
Last Name:BERGIN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9990 DOUBLE R BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-4833
Mailing Address - Country:US
Mailing Address - Phone:753-488-8007
Mailing Address - Fax:775-348-8818
Practice Address - Street 1:242 KING AVENUE
Practice Address - Street 2:SUITE 150
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606
Practice Address - Country:US
Practice Address - Phone:706-475-1870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1847363AS0400X
GA3116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1609829274Medicaid