Provider Demographics
NPI:1316407125
Name:EVERETT, WYLL THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:WYLL
Middle Name:THOMAS
Last Name:EVERETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 GRAFTON RD
Mailing Address - Street 2:
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-8820
Mailing Address - Country:US
Mailing Address - Phone:802-365-7357
Mailing Address - Fax:
Practice Address - Street 1:185 GRAFTON RD
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353-8820
Practice Address - Country:US
Practice Address - Phone:802-365-7357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VT042.0016284207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program