Provider Demographics
NPI:1710996178
Name:BERGMANN, LEE J (PA-C)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:J
Last Name:BERGMANN
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 1:1708 YAKIMA AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5307
Mailing Address - Country:US
Mailing Address - Phone:253-426-4420
Mailing Address - Fax:253-426-4383
Practice Address - Street 1:1708 YAKIMA AVE
Practice Address - Street 2:STE 105
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5307
Practice Address - Country:US
Practice Address - Phone:253-426-4420
Practice Address - Fax:253-426-4383
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0187933OtherSTATE L&I
WA8939078OtherSTATE CRIME VICTIMS
WA8332330Medicaid
WA0194827OtherSTATE L&I
WA0190122OtherSTATE L&I
WA0194827OtherSTATE L&I
R31589Medicare UPIN
WA8939078OtherSTATE CRIME VICTIMS
WAG8868443Medicare PIN