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General NPI Number Information
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NPI Number | 1295376523
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Entity Type | Individual
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Provider Name | EMILY MONTANA BERGERON PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 10/08/2019
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Last Update Date | 01/04/2022
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Provider Practice Location Address
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Address Line | 1417 W 78TH ST APT 1213
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City | TULSA
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State | OK
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Zip | 74132-4633
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Country | US
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Telephone | 918-955-9302
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Fax |
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Provider Business Mailing Address
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Address Line | 4337 E 57TH ST
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City | TULSA
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State | OK
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Zip | 74135-4237
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Country | US
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Telephone | 918-955-9302
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 4722
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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