Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 042-0011500 | VT |
Y | 207QS0010X | Family Doctor - Sports Medicine | 042-0011500 | VT |
NPI | 1083757439 |
---|---|
Provider Name | David Lisle |
First Address | South Burlington, VT 05403-4440 |
Second Address | South Burlington, VT 05403-4440 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 01/09/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8475287 | (05) | WA |