Provider Demographics
NPI:1184617128
Name:BERGMAN, JUDITH (MSN, FNP)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:BERGMAN
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4041 N CENTRAL AVE
Mailing Address - Street 2:BLDG C
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-3313
Mailing Address - Country:US
Mailing Address - Phone:602-279-5262
Mailing Address - Fax:
Practice Address - Street 1:4350 N 19TH AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4602
Practice Address - Country:US
Practice Address - Phone:602-264-9191
Practice Address - Fax:602-532-2973
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1139363LF0000X
AZRN073265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z144752Medicare Oscar/Certification
P80082Medicare UPIN