Basic Information
| Provider Information | |||||||||
| NPI: | 1114333093 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | TRISHA | ||||||||
| MiddleName: | MAE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C, PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JEWELL | ||||||||
| OtherFirstName: | TRISHA | ||||||||
| OtherMiddleName: | MAE | ||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 128 WOODLAND DR | ||||||||
| Address2: | |||||||||
| City: | BARRE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 056413317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022742421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1315 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | ST JOHNSBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8027488141 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2014 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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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 | 225200000X | 1054 | NH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 363AS0400X | 055.0031399 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.