Provider Demographics
NPI:1023465390
Name:BERGART, KATHARINE
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:
Last Name:BERGART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:
Other - Last Name:ENGELMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-739-8999
Mailing Address - Fax:
Practice Address - Street 1:1415 S HWY 89
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8515
Practice Address - Country:US
Practice Address - Phone:307-739-8999
Practice Address - Fax:307-739-4811
Is Sole Proprietor?:No
Enumeration Date:2016-05-17
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60805916363A00000X
WYPA991363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant