Provider Demographics
NPI:1114409000
Name:POLSON, DAVID A
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:POLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21A ESSEX WAY
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-3384
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21A ESSEX WAY
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:VT
Practice Address - Zip Code:05452-3385
Practice Address - Country:US
Practice Address - Phone:802-878-0119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT033.0124926-INTN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program