Provider Demographics
NPI:1336805696
Name:BERG, ALICE ANN
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:ANN
Last Name:BERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 ARBUCKLE COURT
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093
Mailing Address - Country:US
Mailing Address - Phone:530-623-0021
Mailing Address - Fax:
Practice Address - Street 1:81 ARBUCKLE COURT
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:530-623-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant