Healthcare Provider Details

I. General information

NPI: 1285268193
Provider Name (Legal Business Name): JARED THOMAS POLAND AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2020
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE # 5N
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

2211 LOMAS BLVD NE # 5N
ALBUQUERQUE NM
87106-2719
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3535
  • Fax: 505-272-0300
Mailing address:
  • Phone: 505-272-3535
  • Fax: 505-272-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAUD7079
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: