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General NPI Number Information
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NPI Number | 1063749414
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Entity Type | Individual
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Provider Name | AUTUMN M BONDESEN PA
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Gender | Female
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Dates
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Enumeration Date | 11/05/2009
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Last Update Date | 09/25/2012
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Provider Practice Location Address
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Address Line | 44 MAIN ST SUITE 200
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City | RICHFORD
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State | VT
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Zip | 05476-1153
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Country | US
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Telephone | 802-255-5500
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Fax | 802-255-5589
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Provider Business Mailing Address
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Address Line | 6 OUELLET DRIVE
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City | ST ALBANS
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State | VT
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Zip | 05478
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Country | US
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Telephone | 802-578-4979
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Fax | 802-255-5589
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 055-0031000
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License Number State | VT
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