Provider Demographics
NPI:1063749414
Name:BONDESEN, AUTUMN M (PA)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:M
Last Name:BONDESEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:M
Other - Last Name:PICHE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6 OUELLET DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478
Mailing Address - Country:US
Mailing Address - Phone:802-578-4979
Mailing Address - Fax:802-255-5589
Practice Address - Street 1:44 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:RICHFORD
Practice Address - State:VT
Practice Address - Zip Code:05476-1153
Practice Address - Country:US
Practice Address - Phone:802-255-5500
Practice Address - Fax:802-255-5589
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0031000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000445Medicaid