Basic Information
| Provider Information | |||||||||
| NPI: | 1013973858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RATHBURN | ||||||||
| FirstName: | JENIANE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANIELS | ||||||||
| OtherFirstName: | JENIANE | ||||||||
| OtherMiddleName: | L. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | DANIELS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 165 SHERMAN DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058199811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027489405 | ||||||||
| FaxNumber: | 8027484540 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 E MAIN STREET | ||||||||
| Address2: | CONCORD HEALTH CENTER | ||||||||
| City: | CONCORD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 058240355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026952512 | ||||||||
| FaxNumber: | 8026951303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0550030707 | VT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0550031134 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 9000181 | 05 | VT | MEDICAID |