Provider Demographics
NPI:1730288150
Name:BERGESON, DALE (PA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:
Last Name:BERGESON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:1222 E WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:BARRON
Practice Address - State:WI
Practice Address - Zip Code:54812-1765
Practice Address - Country:US
Practice Address - Phone:715-537-3166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI87363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1730288150Medicaid
WI1730288150Medicaid