Provider Demographics
NPI:1588035224
Name:PODOLSKI, STANLEY HENRY IV (PA-C)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:HENRY
Last Name:PODOLSKI
Suffix:IV
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1400 E BOULDER ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-364-6487
Mailing Address - Fax:719-364-6488
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 600
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:719-364-6488
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2016-05-11
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Provider Licenses
StateLicense IDTaxonomies
COPA.0004454363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO458014YLB8Medicare PIN