Basic Information
| Provider Information | |||||||||
| NPI: | 1124047881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICONE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | BLD. A, STE 2-2 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022292663 | ||||||||
| FaxNumber: | 8022296645 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 FISHER RD | ||||||||
| Address2: | BLD A, STE 2-2 | ||||||||
| City: | BERLIN | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8022292663 | ||||||||
| FaxNumber: | 8022296645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/04/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 055-0030160 | VT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 055-0030225 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000216 | 05 | VT | MEDICAID |