Provider Demographics
NPI:1124047881
Name:PICONE, JAMES VINCENT JR (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:VINCENT
Last Name:PICONE
Suffix:JR
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9811
Mailing Address - Country:US
Mailing Address - Phone:802-748-9405
Mailing Address - Fax:802-748-4540
Practice Address - Street 1:137 MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-4415
Practice Address - Country:US
Practice Address - Phone:802-995-2412
Practice Address - Fax:802-334-7991
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030160363A00000X
VT055-0030225363A00000X
VT055.003.1432363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000216Medicaid
AP0518Medicare ID - Type Unspecified
S11587Medicare UPIN
VT9000216Medicaid