Healthcare Provider Details

I. General information

NPI: 1649183690
Provider Name (Legal Business Name): ELLEN MICHELLE POLYAKOV PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N MILITARY TRL STE 107
BOCA RATON FL
33431-6347
US

IV. Provider business mailing address

6567 COBIA CIR
BOYNTON BEACH FL
33437-3641
US

V. Phone/Fax

Practice location:
  • Phone: 305-492-7477
  • Fax:
Mailing address:
  • Phone: 561-699-7933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121679
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: