Provider Demographics
NPI:1639359144
Name:BERGERON, KAREN LEA (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LEA
Last Name:BERGERON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:LEA
Other - Last Name:SYLVIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:535 FAUNCE CORNER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH DARTMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02747-1242
Mailing Address - Country:US
Mailing Address - Phone:508-996-3991
Mailing Address - Fax:
Practice Address - Street 1:535 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-1242
Practice Address - Country:US
Practice Address - Phone:508-996-3991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP2385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA04-3436165OtherHAWTHORN MEDICAL TAX ID