Provider Demographics
NPI:1770569766
Name:FERGEN, BRUCE (FNP)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:FERGEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 W HAYWARD AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85307-1621
Mailing Address - Country:US
Mailing Address - Phone:602-872-8888
Mailing Address - Fax:623-561-6148
Practice Address - Street 1:18700 N 64TH DR
Practice Address - Street 2:STE 201
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7109
Practice Address - Country:US
Practice Address - Phone:623-561-9113
Practice Address - Fax:623-561-6148
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ102517Medicare ID - Type Unspecified
Q41191Medicare UPIN