Healthcare Provider Details

I. General information

NPI: 1508061664
Provider Name (Legal Business Name): MARCUS BERGEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 PROVIDENCE WAY
NEWBERG OR
97132
US

IV. Provider business mailing address

2205 SW 21ST AVE
PORTLAND OR
97201-2358
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-1796
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: