Provider Demographics
NPI:1992344360
Name:BERGER, MARISA EHRLICH (PA-C)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:EHRLICH
Last Name:BERGER
Suffix:
Gender:F
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 1:12902 USF MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-9416
Mailing Address - Country:US
Mailing Address - Phone:813-745-4673
Mailing Address - Fax:
Practice Address - Street 1:311 W IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-6656
Practice Address - Country:US
Practice Address - Phone:941-544-7176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113297363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty