Healthcare Provider Details

I. General information

NPI: 1417155920
Provider Name (Legal Business Name): KRISTIN POLEGA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR SUITE 103
BEVERLY HILLS CA
90210-4310
US

IV. Provider business mailing address

436 N BEDFORD DR SUITE 103
BEVERLY HILLS CA
90210-4310
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-8200
  • Fax: 310-278-8230
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19203
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: