Provider Demographics
NPI:1134445760
Name:BERGMAN, MICHAEL ADAM (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ADAM
Last Name:BERGMAN
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 1:30 SHELBURNE RD
Mailing Address - Street 2:PO BOX 9317
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3628
Mailing Address - Country:US
Mailing Address - Phone:203-276-7076
Mailing Address - Fax:
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-7076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013878363AM0700X
CT003256363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical