Provider Demographics
NPI:1013558188
Name:POLANCO HERNANDEZ, GUSTAVO EMIL (PA)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:EMIL
Last Name:POLANCO HERNANDEZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2626 HALPERIN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-2631
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:2015 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4303
Practice Address - Country:US
Practice Address - Phone:718-583-7736
Practice Address - Fax:718-537-6180
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112633207RC0200X, 2084P0800X, 363A00000X, 207T00000X, 363AS0400X
NY029357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical