Provider Demographics
NPI:1134114770
Name:DOHERTY, GERALD W (PA-C)
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:W
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 KERWIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:VT
Mailing Address - Zip Code:05055-9475
Mailing Address - Country:US
Mailing Address - Phone:802-649-3225
Mailing Address - Fax:802-371-4488
Practice Address - Street 1:79 KERWIN HILL RD
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:VT
Practice Address - Zip Code:05055-9475
Practice Address - Country:US
Practice Address - Phone:802-649-3225
Practice Address - Fax:802-371-4488
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030712363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000203Medicaid
VTAP1397Medicare ID - Type Unspecified
VT9000203Medicaid