Provider Demographics
NPI:1871516161
Name:JAQUA, PATRICIA I (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:I
Last Name:JAQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-8973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8973
Practice Address - Country:US
Practice Address - Phone:802-888-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420007078208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00005932OtherBLUE CROSS
VT0005932Medicaid
VTVT5932Medicare ID - Type Unspecified