Basic Information
| Provider Information | |||||||||
| NPI: | 1801097704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGERON-DESIMONE | ||||||||
| FirstName: | VALERY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DESIMONE | ||||||||
| OtherFirstName: | VALERY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11 TECHNOLOGY DR | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9499233277 | ||||||||
| FaxNumber: | 8558125865 | ||||||||
| Practice Location | |||||||||
| Address1: | 30281 GOLDEN LANTERN | ||||||||
| Address2: | |||||||||
| City: | LAGUNA NIGUEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926775979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494957144 | ||||||||
| FaxNumber: | 9494950270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2007 | ||||||||
| LastUpdateDate: | 04/03/2018 | ||||||||
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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 | 363A00000X | 16648 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.