Provider Demographics
NPI:1710246301
Name:BERGESON, CASEY KENAN
Entity Type:Individual
Prefix:MR
First Name:CASEY
Middle Name:KENAN
Last Name:BERGESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5496 N LITTLE RIVER LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-1768
Mailing Address - Country:US
Mailing Address - Phone:801-830-7797
Mailing Address - Fax:
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-0001
Practice Address - Country:US
Practice Address - Phone:801-830-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0852367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered