Provider Demographics
NPI:1629011226
Name:POLHAMUS, WILLIAM R (PA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:POLHAMUS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:1400 JOHNSTON WILLIS DR
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4765
Practice Address - Country:US
Practice Address - Phone:804-379-8088
Practice Address - Fax:804-794-6067
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-09-15
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Provider Licenses
StateLicense IDTaxonomies
VA0110001563363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0536798OtherAETNA HMO
VA287174OtherSOUTHERN HEALTH
VA540885859OtherCIGNA
VA540885859OtherCORVEL
VA008947104Medicaid
VA540885859OtherC&O EMPLOYEE'S HEALTHCARE
VA540885859OtherFIRST HEALTH/CCN
VA0900325OtherUNITED HEALTHCARE
VA31213OtherSH CARENET
VA540885859OtherMULTIPLAN
VA100679OtherANTHEM HEALTHKEEPERS
VA540885859OtherPRIVATE HEALTHCARE SYSTEM
VA540885859OtherFOCUS
VA540885859OtherVIRGINIA HEALTH NETWORK
VA540885859OtherCOMPMANAGEMENT
VAP00011038OtherRAILROAD MEDICARE
VA0472640003Medicare NSC
VA001018W25Medicare PIN
VA540885859OtherPRIVATE HEALTHCARE SYSTEM