Provider Demographics
NPI:1174083018
Name:BERGERON, COLIN OLIVER (PA-C)
Entity type:Individual
Prefix:MR
First Name:COLIN
Middle Name:OLIVER
Last Name:BERGERON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-1992
Mailing Address - Country:US
Mailing Address - Phone:918-502-3939
Mailing Address - Fax:918-502-3945
Practice Address - Street 1:6161 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1992
Practice Address - Country:US
Practice Address - Phone:918-502-3939
Practice Address - Fax:918-502-3945
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant