Individual
TYANNA BERGERON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
522 S 4TH ST, FULTON, NY 13069-2946
(155) 923-9303
Mailing address
110 W 6TH ST, OSWEGO, NY 13126-2507
(315) 349-5511
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
F03190068
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14421177
CAQH
—
Enumeration date
04/02/2019
Last updated
06/11/2019
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