Basic Information
| Provider Information | |||||||||
| NPI: | 1427144583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLEHNA | ||||||||
| FirstName: | PAVEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602541240 | ||||||||
| FaxNumber: | 3603973128 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 NE 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602541240 | ||||||||
| FaxNumber: | 3603973128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A97249 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD162124 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 41935 | MT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD2015-0793 | NM | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 10464A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 16301 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-18503 | HI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0056351 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-13199 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 51068 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 113948 | AK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD00047152 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8464547 | 05 | WA | MEDICAID |