Provider Demographics
NPI:1821057910
Name:BERGLIN, AMY M (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:BERGLIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12000 ELM CREEK BLVD, SUITE 360
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7076
Mailing Address - Country:US
Mailing Address - Phone:763-420-1010
Mailing Address - Fax:763-420-3710
Practice Address - Street 1:3833 COON RAPIDS BLVD NW STE 120
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2599
Practice Address - Country:US
Practice Address - Phone:763-767-3350
Practice Address - Fax:763-767-0912
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9768207KA0200X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
P83644Medicare UPIN