Provider Demographics
NPI:1518991728
Name:BROCHU, KEVIN JOHN (PA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JOHN
Last Name:BROCHU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 SLATE BARN DR
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-5344
Mailing Address - Country:US
Mailing Address - Phone:802-879-2983
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FAHC EMERGENCY SERVICES
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-1237
Practice Address - Fax:802-847-5963
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT55-0030269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000288Medicaid
VTVN2256Medicare ID - Type Unspecified
VT9000288Medicaid