Provider Demographics
NPI:1982710414
Name:BURGOS, SUZANNE P (PA)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:P
Last Name:BURGOS
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:PO BOX 2000
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-2000
Mailing Address - Country:US
Mailing Address - Phone:802-767-3704
Mailing Address - Fax:802-728-2394
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1381
Practice Address - Country:US
Practice Address - Phone:802-767-3704
Practice Address - Fax:802-728-2394
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTAP1222Medicare ID - Type UnspecifiedMEDICARE
VTP01567Medicare UPIN