Provider Demographics
NPI:1871589150
Name:ELTABBAKH, GEORGIA D (PA)
Entity type:Individual
Prefix:
First Name:GEORGIA
Middle Name:D
Last Name:ELTABBAKH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 HINESBURG RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7612
Mailing Address - Country:US
Mailing Address - Phone:802-859-9500
Mailing Address - Fax:802-859-9944
Practice Address - Street 1:1060 HINESBURG RD
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7612
Practice Address - Country:US
Practice Address - Phone:802-859-9500
Practice Address - Fax:802-859-9944
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030657363AM0700X, 363AS0400X
NY010999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT90000398Medicaid
VT90000398Medicaid
VTAP1022Medicare PIN
S75459Medicare UPIN