MEDICARE: MAAYAN MAIA ROSE POLINGER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	PA2019-0100	NM
2	363A00000X	Physician Assistant
3	363A00000X	Physician Assistant	PA2019-0100	NM

General Provider Information

NPI Number	:	1356990584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAAYAN MAIA ROSE POLINGER PA-C

Provider Business Mailing Address
First Line	:	10705 NELLE AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-3938
Country	:	US
Telephone Number	:	505-470-3103
Fax Number	:

Provider Business Practice Location Address
First Line	:	6801 JEFFERSON ST NE STE 350
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4361
Country	:	US
Telephone Number	:	505-847-4100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/10/2019
Last Update Date	:	02/12/2025

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