Basic Information
| Provider Information | |||||||||
| NPI: | 1275867590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGERON | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S CLEARVIEW AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852093378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809889108 | ||||||||
| FaxNumber: | 4808134460 | ||||||||
| Practice Location | |||||||||
| Address1: | 3611 N CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857191534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208810636 | ||||||||
| FaxNumber: | 5208810637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2009 | ||||||||
| LastUpdateDate: | 03/27/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP3404 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 465975 | 05 | AZ | MEDICAID | Z169168 | 01 | MEDICARE PTAN | OTHER |