MEDICARE: MS. MALLORIE A BERGSTROM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2591-23	WI

General Provider Information

NPI Number	:	1730490012
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MALLORIE A BERGSTROM PA-C

Provider Business Mailing Address
First Line	:	PO BOX 26071
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53226-0071
Country	:	US
Telephone Number	:	414-727-0910
Fax Number	:	414-727-0920

Provider Business Practice Location Address
First Line	:	2727 N MAYFAIR RD STE I
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53222-4400
Country	:	US
Telephone Number	:	414-727-0910
Fax Number	:	414-727-0920

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2010
Last Update Date	:	05/02/2022

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Directions to “ MS. MALLORIE A BERGSTROM PA-C” Practice Location

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