Provider Demographics
NPI:1629322607
Name:BERGERON, KERA (PA-C)
Entity Type:Individual
Prefix:
First Name:KERA
Middle Name:
Last Name:BERGERON
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 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:6029 WALNUT GROVE RD STE 403
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-261-7836
Practice Address - Fax:901-226-0215
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2248363AM0700X, 363AS0400X
MS179363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6186490OtherBCBS
TN2248OtherTN LICENSE
TNT08648AOtherMEDICARE
TNQ000115Medicaid
MS179OtherMS LICENSE