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General NPI Number Information
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NPI Number | 1790339893
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Entity Type | Individual
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Provider Name | ERNESTO MARTELL POLO PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/26/2019
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Last Update Date | 09/19/2024
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Provider Practice Location Address
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Address Line | 16966 CAGAN RIDGE BLVD STE 220
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City | CLERMONT
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State | FL
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Zip | 34714-9656
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Country | US
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Telephone | 321-843-5851
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Fax | 321-843-1673
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Provider Business Mailing Address
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Address Line | 16966 CAGAN RIDGE BLVD STE 220
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City | CLERMONT
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State | FL
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Zip | 34714-9656
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Country | US
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Telephone | 321-843-5851
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Fax | 321-843-1673
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9114867
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9114867
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License Number State | FL
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