Provider Demographics
NPI:1366489122
Name:HAUSER, JOHANNA (PA)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:HAUSER
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 1:128 LAKESIDE AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4939
Mailing Address - Country:US
Mailing Address - Phone:802-448-9719
Mailing Address - Fax:
Practice Address - Street 1:75 TALCOTT RD
Practice Address - Street 2:SUITE 10
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-8121
Practice Address - Country:US
Practice Address - Phone:802-879-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT900224Medicaid
VT900224Medicaid
UTS73571Medicare UPIN