Provider Demographics
NPI:1053388322
Name:POLAK, TRACY (NP)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:POLAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26010
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-6010
Mailing Address - Country:US
Mailing Address - Phone:888-328-4534
Mailing Address - Fax:
Practice Address - Street 1:55 ARCH ST
Practice Address - Street 2:STE 2H
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1423
Practice Address - Country:US
Practice Address - Phone:330-375-4100
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN25262363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2569860Medicaid
OH34145806900OtherOHIO WORKER COMPENSATION
OHS85677Medicare UPIN
OH34145806900OtherOHIO WORKER COMPENSATION