Provider Demographics
NPI:1235895194
Name:BERGERON, AUSTIN CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:CHARLES
Last Name:BERGERON
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 1:207 QUAKER LN FL 1
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-2179
Mailing Address - Country:US
Mailing Address - Phone:401-828-7110
Mailing Address - Fax:401-826-6364
Practice Address - Street 1:207 QUAKER LN FL 1
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-2179
Practice Address - Country:US
Practice Address - Phone:401-828-7110
Practice Address - Fax:401-827-6364
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115307.208200000X
FLPA9115307363AS0400X
RIPA01644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical