Provider Demographics
NPI:1730490012
Name:BERGSTROM, MALLORIE A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MALLORIE
Middle Name:A
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:PO BOX 26071
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-0071
Mailing Address - Country:US
Mailing Address - Phone:414-727-0910
Mailing Address - Fax:414-727-0920
Practice Address - Street 1:2727 N MAYFAIR RD STE I
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-4400
Practice Address - Country:US
Practice Address - Phone:414-727-0910
Practice Address - Fax:414-727-0920
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2591-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant