Provider Demographics
NPI:1104591874
Name:BERGSTROM, MAX FREDERICK (PA-C)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:FREDERICK
Last Name:BERGSTROM
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2918
Mailing Address - Fax:704-945-7681
Practice Address - Street 1:354 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2402
Practice Address - Country:US
Practice Address - Phone:704-786-5122
Practice Address - Fax:704-782-8279
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2025-11-14
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11420363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730007OtherNSC #