Provider Demographics
NPI:1356560775
Name:BERGEN, JOHN ANDREW JR (PTA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANDREW
Last Name:BERGEN
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:20825 N 23RD PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-4426
Mailing Address - Country:US
Mailing Address - Phone:602-569-1065
Mailing Address - Fax:
Practice Address - Street 1:10235 S 51ST ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5218
Practice Address - Country:US
Practice Address - Phone:480-889-3206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0237A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant