Healthcare Provider Details

I. General information

NPI: 1356306963
Provider Name (Legal Business Name): MARY ANN O'BEIRNE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 BELMONT AVE
BRATTLEBORO VT
05301-7110
US

IV. Provider business mailing address

600 BLAIR PARK RD SUITE 190
WILLISTON VT
05495-7586
US

V. Phone/Fax

Practice location:
  • Phone: 802-258-3905
  • Fax: 802-258-4903
Mailing address:
  • Phone: 802-860-1145
  • Fax: 802-872-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0030498
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: