Provider Demographics
NPI:1437644663
Name:POLARD, ZANDRA IRMA
Entity Type:Individual
Prefix:
First Name:ZANDRA
Middle Name:IRMA
Last Name:POLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ZANDRA
Other - Middle Name:IRMA
Other - Last Name:POLARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2715 E RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2426
Mailing Address - Country:US
Mailing Address - Phone:702-848-1696
Mailing Address - Fax:702-463-7283
Practice Address - Street 1:2715 E RUSSELL RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-2426
Practice Address - Country:US
Practice Address - Phone:702-848-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-29
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV$$$$$$$$$Medicaid