Healthcare Provider Details

I. General information

NPI: 1558897173
Provider Name (Legal Business Name): THOMAS PAUL BERGMAN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109-1126
US

IV. Provider business mailing address

6025 LAKE RD STE 200
WOODBURY MN
55125-1710
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-6590
  • Fax:
Mailing address:
  • Phone: 651-999-6800
  • Fax: 651-999-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12457
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: