Provider Demographics
NPI:1659396398
Name:BERG, CARL RONALD (PA-C)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:RONALD
Last Name:BERG
Suffix:
Gender:M
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 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:512-686-0207
Mailing Address - Fax:512-869-2940
Practice Address - Street 1:605 OLD AUSTIN HWY
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602
Practice Address - Country:US
Practice Address - Phone:877-800-5722
Practice Address - Fax:512-332-2180
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00578363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1819898-02Medicaid
TX485427YMP3Medicare UPIN