Healthcare Provider Details

I. General information

NPI: 1093991739
Provider Name (Legal Business Name): AMY MARIE BERGER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 MAPLE LANE
ASHLAND WI
54806
US

IV. Provider business mailing address

1615 MAPLE LANE
ASHLAND WI
54806
US

V. Phone/Fax

Practice location:
  • Phone: 715-685-6010
  • Fax: 719-368-6872
Mailing address:
  • Phone: 715-685-6010
  • Fax: 719-368-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2775
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2775
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2775
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: