Provider Demographics
NPI:1730954934
Name:BERGGREN, TRAVIS EUGENE
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:EUGENE
Last Name:BERGGREN
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 1:118 FREEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-9625
Mailing Address - Country:US
Mailing Address - Phone:607-844-9694
Mailing Address - Fax:607-844-9121
Practice Address - Street 1:118 FREEVILLE RD
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-9625
Practice Address - Country:US
Practice Address - Phone:607-844-8694
Practice Address - Fax:607-844-9121
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY672232163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool