Healthcare Provider Details

I. General information

NPI: 1598908683
Provider Name (Legal Business Name): SARAH STORK TATKO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH JEAN STORK PA

II. Dates (important events)

Enumeration Date: 04/20/2009
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 ROUTE 30 N
BOMOSEEN VT
05732-9647
US

IV. Provider business mailing address

71 ALLEN ST STE 101
RUTLAND VT
05701-4570
US

V. Phone/Fax

Practice location:
  • Phone: 802-468-5641
  • Fax: 802-468-2923
Mailing address:
  • Phone: 800-468-9118
  • Fax: 802-772-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055.0031204
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8053008
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: