Healthcare Provider Details

I. General information

NPI: 1821057910
Provider Name (Legal Business Name): AMY M BERGLIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY MARIE DAVIS

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 11/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3833 COON RAPIDS BLVD NW STE 120
COON RAPIDS MN
55433-2599
US

IV. Provider business mailing address

12000 ELM CREEK BLVD, SUITE 360
MAPLE GROVE MN
55369-7076
US

V. Phone/Fax

Practice location:
  • Phone: 763-767-3350
  • Fax: 763-767-0912
Mailing address:
  • Phone: 763-420-1010
  • Fax: 763-420-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number9768
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9768
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: