Basic Information
| Provider Information | |||||||||
| NPI: | 1093700676 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERTRAND | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3714 GUARDIAN AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472101 | ||||||||
| FaxNumber: | 2522474675 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 ARENDELL ST | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285572901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522472013 | ||||||||
| FaxNumber: | 2522477299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 104067 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1274070001 | 01 | DME MAC JURISDICTION C | OTHER |