Provider Demographics
NPI:1114333093
Name:BULLARD, TRISHA MAE (PA-C, PTA)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:MAE
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PA-C, PTA
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:MAE
Other - Last Name:JEWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:128 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3317
Mailing Address - Country:US
Mailing Address - Phone:802-274-2421
Mailing Address - Fax:
Practice Address - Street 1:1315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819
Practice Address - Country:US
Practice Address - Phone:802-748-8141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1054225200000X
VT055.0031399363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant