Provider Demographics
NPI:1578052882
Name:POLSTON, TRAVIS ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ALEXANDER
Last Name:POLSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:T.
Other - Middle Name:ALEX
Other - Last Name:POLSTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1401 MADISON ST STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1316
Practice Address - Country:US
Practice Address - Phone:206-386-6111
Practice Address - Fax:206-386-6113
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD.61161867207Q00000X
WAMD61161867207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine