Provider Demographics
NPI:1639468184
Name:BERGMAN, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BERGMAN
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 1:815 COMMERCE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-5255
Mailing Address - Country:US
Mailing Address - Phone:419-872-4673
Mailing Address - Fax:419-873-8329
Practice Address - Street 1:702 COMMERCE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-5239
Practice Address - Country:US
Practice Address - Phone:419-872-4673
Practice Address - Fax:419-873-8329
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003246363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDD1846OtherRAILROAD MEDICARE GROUP
OH9344881OtherMEDICARE GROUP
OHH065730Medicare PIN