Provider Demographics
NPI:1548634132
Name:THIBODEAU, ROSS WILLIAM
Entity type:Individual
Prefix:MR
First Name:ROSS
Middle Name:WILLIAM
Last Name:THIBODEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:493 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-7608
Mailing Address - Country:US
Mailing Address - Phone:781-696-5938
Mailing Address - Fax:
Practice Address - Street 1:3 CREST RD
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9753
Practice Address - Country:US
Practice Address - Phone:802-524-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant