Provider Demographics
NPI:1053398636
Name:BERGE, KIMBERLY A (PA-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:BERGE
Suffix:
Gender:F
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 1:433 ST MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-988-1232
Mailing Address - Fax:505-984-1603
Practice Address - Street 1:433 ST MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-988-1232
Practice Address - Fax:505-984-1603
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81PA001363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1699939OtherUHC
10003927OtherLOVELACE
1699939OtherUHC