Healthcare Provider Details

I. General information

NPI: 1992117311
Provider Name (Legal Business Name): JUAN POLANCO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2014
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 BELSPRING RD
FAIRLAWN VA
24141-8567
US

IV. Provider business mailing address

6051 BELSPRING RD
FAIRLAWN VA
24141-8567
US

V. Phone/Fax

Practice location:
  • Phone: 540-509-5443
  • Fax: 855-889-9037
Mailing address:
  • Phone: 540-509-5443
  • Fax: 855-889-9037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701005818
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110008672
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: