Healthcare Provider Details

I. General information

NPI: 1932182292
Provider Name (Legal Business Name): DEBORAH M O HARA PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CRESCENT AVE GREEN MOUNTAIN FAMILY PRACTICE
NORTHFIELD VT
05663-5704
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: 802-485-4161
  • Fax: 802-485-4163
Mailing address:
  • Phone: 802-485-4161
  • Fax: 802-485-4163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0550030353
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0030933
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: