Provider Demographics
NPI:1992117311
Name:POLANCO, JUAN (PA-C)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 E MAIN ST STE 420
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-5085
Mailing Address - Country:US
Mailing Address - Phone:704-604-8488
Mailing Address - Fax:
Practice Address - Street 1:141 E MAIN ST STE 420
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-5085
Practice Address - Country:US
Practice Address - Phone:540-509-5443
Practice Address - Fax:540-440-8924
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008672363AM0700X
VA0701005818101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional