Healthcare Provider Details

I. General information

NPI: 1225676000
Provider Name (Legal Business Name): JARON KIRK POLATIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

140 N BASSETT RD
IDAHO FALLS ID
83402-5665
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-6264
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number9273443-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number63244
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: