Provider Demographics
NPI:1902854201
Name:BUTTERICK, CHARLS G (PAC)
Entity Type:Individual
Prefix:
First Name:CHARLS
Middle Name:G
Last Name:BUTTERICK
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 320
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05667-0320
Mailing Address - Country:US
Mailing Address - Phone:802-454-8336
Mailing Address - Fax:802-454-8339
Practice Address - Street 1:157 TOWNE AVE
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:VT
Practice Address - Zip Code:05667-9425
Practice Address - Country:US
Practice Address - Phone:802-454-8336
Practice Address - Fax:802-454-8339
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030661363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT055-0030661OtherLICENSE
VT367491OtherMVP
VT0008900Medicaid
VTMB0080818OtherDEA