Provider Demographics
NPI:1558472936
Name:POLK, GERALD W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GERALD
Middle Name:W
Last Name:POLK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:OLD HICKORY
Mailing Address - State:TN
Mailing Address - Zip Code:37138-3696
Mailing Address - Country:US
Mailing Address - Phone:615-847-6574
Mailing Address - Fax:615-847-6036
Practice Address - Street 1:1002 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:OLD HICKORY
Practice Address - State:TN
Practice Address - Zip Code:37138-3696
Practice Address - Country:US
Practice Address - Phone:615-847-6574
Practice Address - Fax:615-847-6036
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000659363A00000X
CAPA19769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant