Provider Demographics
NPI:1528206075
Name:GOVERNALE, DEBORAH BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:BETH
Last Name:GOVERNALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 COLCHESTER AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1433
Mailing Address - Country:US
Mailing Address - Phone:802-557-7182
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-21
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031028363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical