Basic Information
| Provider Information | |||||||||
| NPI: | 1528499555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGMAN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 EVES DR STE A100 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533126 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
| FaxNumber: | 6092679457 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 YOUNG AVE STE 245 | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092679400 | ||||||||
| FaxNumber: | 6092679457 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 25MT00155300 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 25MP00481600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.