Provider Demographics
NPI:1770691651
Name:BERTHIAUME, NORMAN LEO (FNP-C)
Entity type:Individual
Prefix:MR
First Name:NORMAN
Middle Name:LEO
Last Name:BERTHIAUME
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ROBERTS AVE NE
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-7101
Mailing Address - Country:US
Mailing Address - Phone:701-797-2221
Mailing Address - Fax:701-797-2457
Practice Address - Street 1:1200 ROBERTS AVE NE
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-7101
Practice Address - Country:US
Practice Address - Phone:701-797-2221
Practice Address - Fax:701-797-2457
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER015780363LF0000X
NDR34592363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME128170099Medicaid