Provider Demographics
NPI:1366876476
Name:SELMONT, MICHAEL J (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:SELMONT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 WHITNEY AVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3691
Mailing Address - Country:US
Mailing Address - Phone:203-281-4463
Mailing Address - Fax:
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-281-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002943363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant