Provider Demographics
NPI:1780670398
Name:BERGSTROM, DEBRA L (NP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:L
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 10TH ST STE C
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5012
Mailing Address - Country:US
Mailing Address - Phone:575-437-4533
Mailing Address - Fax:575-437-5009
Practice Address - Street 1:1401 10TH ST STE C
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5012
Practice Address - Country:US
Practice Address - Phone:575-437-4533
Practice Address - Fax:575-437-5009
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ057927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ560103Medicaid
AZ72557Medicare ID - Type Unspecified
AZ560103Medicaid