Healthcare Provider Details

I. General information

NPI: 1902854201
Provider Name (Legal Business Name): CHARLS G BUTTERICK P.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 TOWNE AVE
PLAINFIELD VT
05667-9425
US

IV. Provider business mailing address

PO BOX 320
PLAINFIELD VT
05667-0320
US

V. Phone/Fax

Practice location:
  • Phone: 802-454-8336
  • Fax: 802-454-8339
Mailing address:
  • Phone: 802-454-8336
  • Fax: 802-454-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0030661
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: