Provider Demographics
NPI:1366432478
Name:LAVERTY, EDWARD JOSEPH (PA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOSEPH
Last Name:LAVERTY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:2005-10-28
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VT055.0031605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0AP0387Medicaid
VT00038485OtherBLUE CROSS
UT341726OtherMVP
542157OtherTRICARE
NH30010636Medicaid
NH30010636Medicaid
S42157Medicare UPIN