Provider Demographics
NPI:1437196870
Name:BERGESON, ERIK (PA)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:BERGESON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1334
Mailing Address - Country:US
Mailing Address - Phone:509-838-2531
Mailing Address - Fax:
Practice Address - Street 1:400 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1334
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004184363AM0700X
WAPA60120173363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00426902OtherRAILROAD MEDICARE
AL009933554Medicaid
GA865184205AMedicaid
GA97WCGZJMedicare PIN
GAP00426902OtherRAILROAD MEDICARE
GA865184205AMedicaid