Healthcare Provider Details

I. General information

NPI: 1467605444
Provider Name (Legal Business Name): JOHN ANDREW BERG PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2008
Last Update Date: 11/01/2022
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BRANSON LANDING BLVD STE 100
BRANSON MO
65616-2152
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 417-348-8646
  • Fax: 417-335-7529
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2013031939
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: