Healthcare Provider Details

I. General information

NPI: 1154321842
Provider Name (Legal Business Name): HEATHER ANNE LAROSE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 PINE ST
BURLINGTON VT
05401
US

IV. Provider business mailing address

600 BLAIR PARK RD SUITE 190
WILLISTON VT
05495
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-0693
  • Fax: 802-860-6613
Mailing address:
  • Phone: 802-872-4343
  • Fax: 802-872-0282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011444
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0550030631
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: