Provider Demographics
NPI:1780093641
Name:BERGANINI, EMILY VICTORIA (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:VICTORIA
Last Name:BERGANINI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 E HARMONY RD
Mailing Address - Street 2:UNIT 170
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528-3413
Mailing Address - Country:US
Mailing Address - Phone:970-493-6337
Mailing Address - Fax:970-493-3528
Practice Address - Street 1:2121 E HARMONY RD
Practice Address - Street 2:UNIT 170
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-3413
Practice Address - Country:US
Practice Address - Phone:970-493-6337
Practice Address - Fax:970-493-3528
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017831363A00000X
COPA.0004891363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO23185074Medicaid
CO552056YLB8Medicare PIN