Basic Information
Provider Information | |||||||||
NPI: | 1598908683 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TATKO | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | STORK | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STORK | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | JEAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 71 ALLEN ST | ||||||||
Address2: | STE 101 | ||||||||
City: | RUTLAND | ||||||||
State: | VT | ||||||||
PostalCode: | 057014570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004689118 | ||||||||
FaxNumber: | 8027727973 | ||||||||
Practice Location | |||||||||
Address1: | 275 ROUTE 30 N | ||||||||
Address2: |   | ||||||||
City: | BOMOSEEN | ||||||||
State: | VT | ||||||||
PostalCode: | 057329647 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8024685641 | ||||||||
FaxNumber: | 8024682923 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/20/2009 | ||||||||
LastUpdateDate: | 04/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 8053008 | VT | N |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 363AM0700X | 055.0031204 | VT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 9000662 | 05 | VT |   | MEDICAID |