MEDICARE: ERNESTO MARTELL POLO 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	363A00000X	Physician Assistant	PA9114867	FL
2	363AS0400X	Surgical Physician Assistant	PA9114867	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790339893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERNESTO MARTELL POLO PA-C

Provider Business Mailing Address
First Line	:	16966 CAGAN RIDGE BLVD STE 220
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34714-9656
Country	:	US
Telephone Number	:	321-843-5851
Fax Number	:	321-843-1673

Provider Business Practice Location Address
First Line	:	16966 CAGAN RIDGE BLVD STE 220
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34714-9656
Country	:	US
Telephone Number	:	321-843-5851
Fax Number	:	321-843-1673

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

Provider Enumeration Date	:	07/26/2019
Last Update Date	:	09/19/2024

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