Provider Demographics
NPI:1801156385
Name:BERGSTROM, ELIZA A (CAA)
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:A
Last Name:BERGSTROM
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:A
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-8100
Practice Address - Fax:608-263-0575
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100023498Medicaid