Provider Demographics
NPI:1679653596
Name:POLANCO, MARIANA (LSA)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21109 42ND AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2807
Mailing Address - Country:US
Mailing Address - Phone:281-703-2929
Mailing Address - Fax:
Practice Address - Street 1:1086 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4854
Practice Address - Country:US
Practice Address - Phone:281-703-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00278246Z00000X
IL03-162246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other