Provider Demographics
NPI:1861566135
Name:BEAUREGARD, THOMAS E (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:E
Last Name:BEAUREGARD
Suffix:
Gender:M
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 1:3300 ROUTE 144
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:VT
Mailing Address - Zip Code:05743-9648
Mailing Address - Country:US
Mailing Address - Phone:802-537-3363
Mailing Address - Fax:
Practice Address - Street 1:82 CATAMOUNT PARK
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:VT
Practice Address - Zip Code:05753-1292
Practice Address - Country:US
Practice Address - Phone:802-388-7185
Practice Address - Fax:802-388-3445
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0007984Medicaid
S94168Medicare UPIN
VT0007984Medicaid