Provider Demographics
NPI:1427144583
Name:POLEHNA, PAVEL (MD)
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:POLEHNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-254-1240
Mailing Address - Fax:360-397-3128
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-254-1240
Practice Address - Fax:360-397-3128
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97249207Q00000X
ORMD162124207Q00000X
MT41935207Q00000X
NMMD2015-0793207Q00000X
WY10464A207Q00000X
NV16301207Q00000X
HIMD-18503207Q00000X
CODR.0056351207Q00000X
IDM-13199207Q00000X
AZ51068207Q00000X
AK113948207Q00000X
WAMD00047152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8464547Medicaid
WA8861946Medicare PIN