Provider Demographics
NPI:1326149220
Name:WHITMAN, SUSAN (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WHITMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 JOHNNIE BROOK RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VT
Mailing Address - Zip Code:05477-4412
Mailing Address - Country:US
Mailing Address - Phone:802-578-5146
Mailing Address - Fax:
Practice Address - Street 1:425 PEARL ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-3308
Practice Address - Country:US
Practice Address - Phone:802-656-3350
Practice Address - Fax:802-656-8001
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030747363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000241Medicaid
69001OtherBLUE CROSS BLUE SHIELD
0030747OtherFLETCHER ALLEN PREFERRED
69001OtherVERMONT MANAGED CARE
793628OtherMVP
VTQ59673Medicare UPIN