Healthcare Provider Details

I. General information

NPI: 1548858053
Provider Name (Legal Business Name): JONATHAN DUVALL SPEER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2021
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 SHERMAN DR
ST JOHNSBURY VT
05819-9811
US

IV. Provider business mailing address

165 SHERMAN DR
ST JOHNSBURY VT
05819-9811
US

V. Phone/Fax

Practice location:
  • Phone: 802-748-5041
  • Fax:
Mailing address:
  • Phone: 802-748-9405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0031000
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: