Provider Demographics
NPI:1316976202
Name:BERGEN, JOANNE A (RPA-C)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:A
Last Name:BERGEN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 278980
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:995 SENATOR KEATING BLVD
Practice Address - Street 2:SUITE 200 BUILDING E
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2775
Practice Address - Country:US
Practice Address - Phone:585-244-8817
Practice Address - Fax:585-279-3612
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3939363AM0700X
NY003939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR82238Medicare UPIN
NYDD0192Medicare PIN