Provider Demographics
NPI:1134647274
Name:BERGMAN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 VANDALIA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1312
Mailing Address - Country:US
Mailing Address - Phone:651-698-2406
Mailing Address - Fax:
Practice Address - Street 1:201 N VICTORY DR STE 211
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5398
Practice Address - Country:US
Practice Address - Phone:507-387-5581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1728514363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health