Basic Information
| Provider Information | |||||||||
| NPI: | 1205843927 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARRABEE | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, MED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 76 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VERGENNES | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054911155 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 42-0010915 | VT | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD2019-0730 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1011378 | 05 | VT | MEDICAID |