Provider Demographics
NPI:1891785671
Name:CALLAHAN, RICHARD Q (MSPA, PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:Q
Last Name:CALLAHAN
Suffix:
Gender:M
Credentials:MSPA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 COLCHESTER AVE
Mailing Address - Street 2:DERMATOLOGY - ACC/WP-5
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1473
Mailing Address - Country:US
Mailing Address - Phone:802-847-4570
Mailing Address - Fax:802-847-3364
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:DERMATOLOGY - ACC/WP-5
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-4570
Practice Address - Fax:802-847-3364
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030786363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT055-0030786OtherLICENSE