Basic Information
| Provider Information | |||||||||
| NPI: | 1033196639 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GILL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORCORAN | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 104 PORTER DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 057538527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023888808 | ||||||||
| FaxNumber: | 8023888322 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 PORTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURY | ||||||||
| State: | VT | ||||||||
| PostalCode: | 05753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023887959 | ||||||||
| FaxNumber: | 8023888136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 1010018668 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1011539 | 05 | VT | MEDICAID |