Basic Information
| Provider Information | |||||||||
| NPI: | 1750553921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERGMOOSER | ||||||||
| FirstName: | BOBBI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 N MAIN ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044122055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079924032 | ||||||||
| FaxNumber: | 2079924034 | ||||||||
| Practice Location | |||||||||
| Address1: | 489 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079737000 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2008 | ||||||||
| LastUpdateDate: | 04/29/2013 | ||||||||
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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 | 367500000X | R049891 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 079296 | 01 | CCNA | OTHER | R049891 | 01 | ME | MAINE STATE BOARD OF NURS | OTHER | 4704108789 | 01 | MI | STATE OF MICHIGAN | OTHER |