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General NPI Number Information
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NPI Number | 1336771260
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Entity Type | Individual
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Provider Name | SAMUEL ANTONIO RODRIGUEZ POLANCO SA-C
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Gender | Male
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Dates
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Enumeration Date | 02/08/2020
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Last Update Date | 02/08/2020
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Provider Practice Location Address
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Address Line | 8824 242ND ST
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City | BELLEROSE
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State | NY
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Zip | 11426-1241
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Country | US
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Telephone | 781-346-7191
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Fax |
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Provider Business Mailing Address
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Address Line | 8824 242ND ST
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City | BELLEROSE
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State | NY
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Zip | 11426-1241
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Country | US
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Telephone | 781-346-7191
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | 18-152
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License Number State | NY
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