Provider Demographics
NPI:1992286223
Name:BERGH, TRAE JORDAN (PA-C)
Entity type:Individual
Prefix:
First Name:TRAE
Middle Name:JORDAN
Last Name:BERGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 S KEYRELL DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-7304
Mailing Address - Country:US
Mailing Address - Phone:605-553-6458
Mailing Address - Fax:
Practice Address - Street 1:575 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5312
Practice Address - Country:US
Practice Address - Phone:605-217-2667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1156363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical