Provider Demographics
NPI:1285031872
Name:GOULETTE, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:GOULETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-864-6309
Mailing Address - Fax:802-860-4313
Practice Address - Street 1:617 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1601
Practice Address - Country:US
Practice Address - Phone:802-864-6309
Practice Address - Fax:802-860-4313
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031230363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical