Healthcare Provider Details

I. General information

NPI: 1336772730
Provider Name (Legal Business Name): LUKE WILLIAM BERGLUND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2020
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1132 ASTER LN
WINNECONNE WI
54986-9166
US

IV. Provider business mailing address

323 S 18TH AVE
STURGEON BAY WI
54235-1401
US

V. Phone/Fax

Practice location:
  • Phone: 262-893-3035
  • Fax:
Mailing address:
  • Phone: 920-743-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60232
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: