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General NPI Number Information
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NPI Number | 1992117311
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Entity Type | Individual
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Provider Name | JUAN POLANCO PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/21/2014
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Last Update Date | 01/09/2024
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Provider Practice Location Address
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Address Line | 141 E MAIN ST STE 420
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City | PULASKI
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State | VA
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Zip | 24301-5085
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Country | US
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Telephone | 540-509-5443
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Fax | 540-440-8924
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Provider Business Mailing Address
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Address Line | 141 E MAIN ST STE 420
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City | PULASKI
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State | VA
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Zip | 24301-5085
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Country | US
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Telephone | 704-604-8488
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110008672
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 0701005818
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License Number State | VA
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