Provider Demographics
NPI:1831488105
Name:STOLL, PATRICK BLAKE (PTA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:BLAKE
Last Name:STOLL
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 SHELDON ROAD
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478
Mailing Address - Country:US
Mailing Address - Phone:802-524-6534
Mailing Address - Fax:802-524-2429
Practice Address - Street 1:596 SHELDON ROAD
Practice Address - Street 2:
Practice Address - City:ST ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:802-524-6534
Practice Address - Fax:802-524-2429
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT041.0000504225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant