Provider Demographics
NPI:1538366828
Name:BERGERON, KATEY PONDER (PA-C)
Entity type:Individual
Prefix:
First Name:KATEY
Middle Name:PONDER
Last Name:BERGERON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:PONDER
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5000 HENNESSY BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4375
Mailing Address - Country:US
Mailing Address - Phone:225-765-8853
Mailing Address - Fax:225-765-1700
Practice Address - Street 1:5000 HENNESSY BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4375
Practice Address - Country:US
Practice Address - Phone:225-765-8853
Practice Address - Fax:225-765-1700
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1369497Medicaid
MS04655037Medicaid
5DX80PH13Medicare PIN