Provider Demographics
NPI:1326097767
Name:BREASURE, KEITH J (MSN,NP)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:J
Last Name:BREASURE
Suffix:
Gender:M
Credentials:MSN,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:ATT: CVMC FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-371-4316
Mailing Address - Fax:802-371-4579
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-371-4316
Practice Address - Fax:802-371-4579
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG0000383363L00000X
VT101.0096152363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTY400188874Medicare PIN
Q58509Medicare UPIN
NJ0096296Medicaid
MD036MN174Medicare PIN
DE1000038788Medicaid
MD411561500Medicaid