Healthcare Provider Details

I. General information

NPI: 1669499430
Provider Name (Legal Business Name): JUSTINE GADD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 05/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 GRANGER RD SUITE 2
BERLIN VT
05602-9516
US

IV. Provider business mailing address

PO BOX 547 CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-5810
  • Fax: 802-371-4821
Mailing address:
  • Phone: 802-225-5810
  • Fax: 802-371-4821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030702
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: