Provider Demographics
NPI:1053548727
Name:HERGERT, JOHN C (CRNA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:HERGERT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 HARRISON PKWY
Mailing Address - Street 2:SUITE 200 MAILSTOP SH-9A
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2896
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-851-1746
Practice Address - Street 1:160 ALLEN STREET
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-747-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0054298367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered