Healthcare Provider Details

I. General information

NPI: 1932112752
Provider Name (Legal Business Name): ELAINE E. POLK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 EAST NIZHONI BLVD.
GALLUP NM
87301-1337
US

IV. Provider business mailing address

4320 DIPLOMACY DR ATTN: SHERRY REEDY
ANCHORAGE AK
99508-5925
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax: 505-726-8671
Mailing address:
  • Phone: 907-729-3971
  • Fax: 907-729-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number720
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: