Provider Demographics
NPI:1326669516
Name:BERGMANN, KAYLA ALEXIS (PA)
Entity type:Individual
Prefix:MS
First Name:KAYLA
Middle Name:ALEXIS
Last Name:BERGMANN
Suffix:
Gender:
Credentials:PA
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Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-747-7236
Mailing Address - Fax:314-362-8099
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DEPT RADIATION ONCOLOGY, LL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-7236
Practice Address - Fax:314-362-8099
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085008243363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220130292Medicaid