Provider Demographics
NPI:1992358550
Name:BERGSTROM, BENJAMIN SCOTT (DNP)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:SCOTT
Last Name:BERGSTROM
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21219 N 38TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4963
Mailing Address - Country:US
Mailing Address - Phone:480-369-1976
Mailing Address - Fax:
Practice Address - Street 1:655 SIERRA ROSE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2060
Practice Address - Country:US
Practice Address - Phone:775-770-2705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN178752163W00000X
AZ228542367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse