Healthcare Provider Details

I. General information

NPI: 1285013284
Provider Name (Legal Business Name): HUNTER BERGAMASCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2015
Last Update Date: 05/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 BAIR ISLAND RD APT 401
REDWOOD CITY CA
94063-5550
US

IV. Provider business mailing address

PO BOX 27573
SAN FRANCISCO CA
94127-0573
US

V. Phone/Fax

Practice location:
  • Phone: 650-321-9999
  • Fax:
Mailing address:
  • Phone: 650-321-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License NumberD04742501
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: