Healthcare Provider Details

I. General information

NPI: 1952811564
Provider Name (Legal Business Name): EMILIE LISE BESL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVENUE DIVISION OF DERMATOLOGY
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4570
  • Fax: 802-847-3364
Mailing address:
  • Phone: 802-847-4570
  • Fax: 802-847-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055.0031376
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: