Provider Demographics
NPI:1659399400
Name:BERGERON, LOUIS CHAD (PA)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:CHAD
Last Name:BERGERON
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 1:740 W PLYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-3282
Mailing Address - Country:US
Mailing Address - Phone:386-734-9122
Mailing Address - Fax:
Practice Address - Street 1:740 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3282
Practice Address - Country:US
Practice Address - Phone:386-734-9122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.A10345.RX363A00000X
FLPA9101072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1331040Medicaid
LA1331040Medicaid
LAQ43482Medicare UPIN
LA5CQ60PB06Medicare PIN