Healthcare Provider Details

I. General information

NPI: 1063749414
Provider Name (Legal Business Name): AUTUMN M BONDESEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN M PICHE

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 09/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MAIN ST SUITE 200
RICHFORD VT
05476-1153
US

IV. Provider business mailing address

6 OUELLET DRIVE
ST ALBANS VT
05478
US

V. Phone/Fax

Practice location:
  • Phone: 802-255-5500
  • Fax: 802-255-5589
Mailing address:
  • Phone: 802-578-4979
  • Fax: 802-255-5589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0031000
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: