Provider Demographics
NPI:1215704416
Name:ENSALATA, TOMAS T (PA-C)
Entity type:Individual
Prefix:
First Name:TOMAS
Middle Name:T
Last Name:ENSALATA
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 1:1057 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:VERGENNES
Mailing Address - State:VT
Mailing Address - Zip Code:05491-8527
Mailing Address - Country:US
Mailing Address - Phone:802-233-1447
Mailing Address - Fax:
Practice Address - Street 1:8 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4651
Practice Address - Country:US
Practice Address - Phone:802-770-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-07
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical