Healthcare Provider Details

I. General information

NPI: 1790339893
Provider Name (Legal Business Name): ERNESTO MARTELL POLO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2019
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16966 CAGAN RIDGE BLVD STE 220
CLERMONT FL
34714-9656
US

IV. Provider business mailing address

16966 CAGAN RIDGE BLVD STE 220
CLERMONT FL
34714-9656
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-5851
  • Fax: 321-843-1673
Mailing address:
  • Phone: 321-843-5851
  • Fax: 321-843-1673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114867
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9114867
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: