Basic Information
| Provider Information | |||||||||
| NPI: | 1225124142 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNIGER | ||||||||
| FirstName: | MARILISE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARANCIK | ||||||||
| OtherFirstName: | MARILISE | ||||||||
| OtherMiddleName: | B. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6350 CENTER DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235024107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572135700 | ||||||||
| FaxNumber: | 7572135701 | ||||||||
| Practice Location | |||||||||
| Address1: | 5900 LAKE WRIGHT DR | ||||||||
| Address2: | |||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 235021871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574668683 | ||||||||
| FaxNumber: | 7574668892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA02861 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110004002 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 202340001 (MDACC) | 05 | TX | MEDICAID | 1225124142 | 05 | VA | MEDICAID | 88N193 | 01 | TX | BCBS (MDACC) | OTHER | 970017769 | 01 | TX | RR MEDICARE (MDACC) | OTHER |