Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 235165 | AZ |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 235165 | AZ |
N | 363LG0600X | Nurse Practitioner - Gerontology | 235165 | AZ |
NPI | 1598399677 |
---|---|
Provider Name | Mr. Michael John Berg |
First Address | Gilbert, AZ 85298-4313 |
Second Address | Gilbert, AZ 85298-4313 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/02/2020 |
Last Update Date | 05/10/2020 |