Healthcare Provider Details

I. General information

NPI: 1477242584
Provider Name (Legal Business Name): ERIN MARIE POLAK CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BAKERS RIDGE RD
MORGANTOWN WV
26508-1500
US

IV. Provider business mailing address

136 BAKERS DR
MORGANTOWN WV
26505-2573
US

V. Phone/Fax

Practice location:
  • Phone: 304-538-4300
  • Fax:
Mailing address:
  • Phone: 304-288-3293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number108379
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: