Basic Information
| Provider Information | |||||||||
| NPI: | 1508003575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERGNER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1178 KINOOLE ST | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967207206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089343214 | ||||||||
| FaxNumber: | 8089614909 | ||||||||
| Practice Location | |||||||||
| Address1: | 1178 KINOOLE ST | ||||||||
| Address2: | BUILDING B | ||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967207206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8089343214 | ||||||||
| FaxNumber: | 8089614909 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2009 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-64478 | HI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.