Provider Demographics
NPI:1386744282
Name:POLING, JON C (PA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:POLING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:35200 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-1748
Mailing Address - Country:US
Mailing Address - Phone:760-328-8884
Mailing Address - Fax:760-202-3931
Practice Address - Street 1:35200 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1748
Practice Address - Country:US
Practice Address - Phone:760-328-8884
Practice Address - Fax:760-202-3931
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA12140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PA121400Medicare ID - Type UnspecifiedMEDICARE PROVIDER
CAS06613Medicare UPIN