Provider Demographics
NPI:1659899789
Name:BERGSTROM, KIRSTIN LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:LEA
Last Name:BERGSTROM
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 1:1600 FILLMORE ST APT 1-127
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1598
Mailing Address - Country:US
Mailing Address - Phone:678-849-5256
Mailing Address - Fax:
Practice Address - Street 1:4900 E KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-2365
Practice Address - Country:US
Practice Address - Phone:303-756-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant