Provider Demographics
NPI:1154321842
Name:LAROSE, HEATHER ANNE (PAC)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:ANNE
Last Name:LAROSE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 BLAIR PARK RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495
Mailing Address - Country:US
Mailing Address - Phone:802-872-4343
Mailing Address - Fax:802-872-0282
Practice Address - Street 1:789 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-864-0693
Practice Address - Fax:802-860-6613
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011444363A00000X
VT0550030631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002358Medicaid
VT00038362OtherBCBS
VTVN0879Medicare PIN
VT0002358Medicaid
VTP09069Medicare UPIN
VT00038362OtherBCBS