Provider Demographics
NPI:1396162889
Name:JOURNAL, ALPHA BERGER
Entity type:Individual
Prefix:
First Name:ALPHA
Middle Name:BERGER
Last Name:JOURNAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 SE LENNARD RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-4742
Mailing Address - Country:US
Mailing Address - Phone:772-335-1812
Mailing Address - Fax:772-335-1825
Practice Address - Street 1:2115 SE LENNARD RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-4742
Practice Address - Country:US
Practice Address - Phone:772-335-1812
Practice Address - Fax:772-335-1825
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-24
Last Update Date:2014-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107784363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant