Basic Information
Provider Information | |||||||||
NPI: | 1124344080 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | POLSLEY | ||||||||
FirstName: | CHRIS | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 S NEVADA AVENUE | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 81401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9702497751 | ||||||||
FaxNumber: | 9702495029 | ||||||||
Practice Location | |||||||||
Address1: | 836 S. TOWNSEND, SUITE A | ||||||||
Address2: |   | ||||||||
City: | MONTROSE | ||||||||
State: | CO | ||||||||
PostalCode: | 81401 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706159120 | ||||||||
FaxNumber: | 9702401139 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2010 | ||||||||
LastUpdateDate: | 08/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2994 | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 521319ZV3Y | 01 | CO | MEDICARE FOR CEDAR POINT HEALTH | OTHER | 90132360 | 05 | CO |   | MEDICAID | P01705524 | 01 | CO | RAILROAD MEDICARE FOR CEDAR POINT HEALTH | OTHER |