Basic Information
| Provider Information | |||||||||
| NPI: | 1588811467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGSTROM | ||||||||
| FirstName: | CHRISTINA | ||||||||
| MiddleName: | NG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16811 SE MCGILLIVRAY BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986833404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607358100 | ||||||||
| FaxNumber: | 3602531781 | ||||||||
| Practice Location | |||||||||
| Address1: | 16811 SE MCGILLIVRAY BLVD | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986833404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607358100 | ||||||||
| FaxNumber: | 3602531781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 01/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD60087862 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD160810 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01238398 | 01 | OR | RR MEDICARE (PH&S) | OTHER | 213006 | 05 | OR | MEDICAID |