Basic Information
| Provider Information | |||||||||
| NPI: | 1902166481 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGMANN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROBINSON | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1014 N SPRINGBROOK RD | ||||||||
| Address2: | STE B | ||||||||
| City: | NEWBERG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971322061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034498988 | ||||||||
| FaxNumber: | 5038949194 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 NW 22ND AVE | ||||||||
| Address2: | STE 500 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032275050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2012 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201501470NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 201501470NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 201501470NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LG0600X | 201501470NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | 201501470NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.