Provider Demographics
NPI:1124234455
Name:BERGSRUD, DEANE (PA)
Entity type:Individual
Prefix:MR
First Name:DEANE
Middle Name:
Last Name:BERGSRUD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 KENMORE AVE
Mailing Address - Street 2:SUITE 900
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1313
Mailing Address - Country:US
Mailing Address - Phone:703-212-0700
Mailing Address - Fax:703-212-0705
Practice Address - Street 1:4660 KENMORE AVE
Practice Address - Street 2:SUITE 900
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1313
Practice Address - Country:US
Practice Address - Phone:703-212-0700
Practice Address - Fax:703-212-0705
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110000120363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant