Provider Demographics
NPI:1508852187
Name:BERGERON, KENNETH PAUL (CRNA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:PAUL
Last Name:BERGERON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 459
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70571-0459
Mailing Address - Country:US
Mailing Address - Phone:337-849-5315
Mailing Address - Fax:318-442-1586
Practice Address - Street 1:539 E PRUDHOMME ST
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-6499
Practice Address - Country:US
Practice Address - Phone:337-943-7128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN083404367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1620513Medicaid
LA1620513Medicaid
LA4H364C203Medicare PIN
LA4H364Medicare PIN